Lower Epworth Sleepiness Scale Scores Research Articles

Olfactory Dysfunction and Long-Term Trajectories of Sleep Disorders among early Parkinson’s Disease: Findings from a Longitudinal Cohort

Background: Previous studies have suggested a connection between impaired olfactory function and an increased risk of rapid eye movement sleep behavior disorder (RBD) in individuals diagnosed with Parkinson’s disease (PD). However, there is a gap in knowledge regarding the potential impact of olfactory dysfunction on the long-term patterns of sleep disorders among early PD patients. Methods: Data from the Parkinson’s Progression Markers Initiative program included 589 participants with assessments of sleep disorders using the Epworth Sleepiness Scale (ESS) and RBD Screening Questionnaire (RBDSQ). Olfactory dysfunction at baseline was measured using the University of Pennsylvania Smell Identification Test. Trajectories of sleep disorders over a 5-year follow-up were identified using group-based trajectory modeling, and the relationship between olfactory dysfunction and sleep disorder trajectories was examined through binomial logistic regression. Results: Two distinct trajectories of sleep disorders over the 5-year follow-up period were identified, characterized by maintaining a low or high ESS score and a low or high RBDSQ score. An inversion association was observed between olfactory function measures and trajectories of excessive daytime sleepiness (odds ratio [OR] = 0.97, 95% confidence interval [CI] 0.95, 1.00, p = 0.038), after controlling for potential covariates. Similarly, olfactory function showed a significant association with lower trajectories of probable RBD (OR = 0.96, 95% CI 0.94, 0.98, p = 0.001) among early PD individuals. Consistent findings were replicated across alternative analytical models. Conclusions: Our findings indicated that olfactory dysfunction was associated with unfavorable long-term trajectories of sleep disorders among early PD.

0759 A real world study assessing patient satisfaction in the primary care setting in relation to excessive daytime sleepiness in participants with obstructive sleep apnea

Abstract Introduction Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA), despite positive airway pressure (PAP) therapy. These analyses evaluated EDS prevalence and its relationship with satisfaction with care in participants with OSA receiving OSA care in a primary care setting. Methods US residents (aged ≥18 years, self-reported physician OSA diagnosis [1/1/2015–3/31/2020]) completed a survey in Evidation Health’s Achievement app assessing Epworth Sleepiness Scale (ESS), specialties of healthcare providers (HCPs) treating OSA, PAP usage, and satisfaction with HCPs and overall OSA care. Self-reported PAP use was categorized: nonuse, nonadherent (<4 h/night, <5 d/wk), intermediate (4–6 h/night, ≥5 d/wk), or highly-adherent (≥6 h/night, ≥5 d/wk) (PAP-adherent=intermediate+highly-adherent groups). Linear modeling assessed the relationship between PAP use and ESS score; logistic regression assessed impacts of PAP adherence and EDS on satisfaction with care. P-values are uncontrolled for multiplicity. Results Participants (N=2289) were 50.3% female; 82.5% White; 44.8±11.1 years old (mean±SD); with BMI 35.4±8.7 kg/m2; 42.5% had EDS (ESS>10). OSA was primarily managed by sleep specialists (43.5%), general practitioners (GPs) (42.5% [28.9% saw a GP only; 13.6% saw a GP and a specialist/pulmonologist]), and/or pulmonologists (18.0%). Among participants with OSA managed by a GP only (n=662), proportions (95% CI) with EDS were: PAP nonuse (49% [42.8–54.9]), nonadherent (47% [31.5–63.2]), intermediate (47% [33.4–60.8]), and highly-adherent (35% [29.3–39.9]). Linear modeling (PAP users; n=398) showed an additional h/night of PAP use was associated with lower ESS scores (estimate [SE], –0.26 [0.13]; P<0.05); logistic regression showed association between PAP adherence and higher satisfaction with HCPs (adjOR=2.26; 95% CI=1.09–4.70; P<0.05) and OSA care (adjOR=1.58; 95% CI=0.75–3.36; P>0.05). There was an association between presence of EDS and lower satisfaction with their HCPs (adjOR=0.62; 95% CI=0.39–0.99; P<0.05) and OSA care (adjOR=0.49; 95% CI=0.31–0.79; P<0.05). Conclusion In a real-world population of participants with OSA receiving OSA care from GPs, EDS was common, even among highly-adherent PAP users. ESS scores were generally lower with increasing PAP adherence. PAP adherence was associated with increased satisfaction with their HCPs; EDS was associated with lower satisfaction with HCPs and overall OSA care. Support (If Any) Jazz Pharmaceuticals

A REAL-WORLD STUDY ASSESSING THE RELATIONSHIP BETWEEN POSITIVE AIRWAY PRESSURE TREATMENT, EXCESSIVE DAYTIME SLEEPINESS, AND PATIENT SATISFACTION IN OSA

TOPIC: Sleep Disorders TYPE: Original Investigations PURPOSE: Excessive daytime sleepiness (EDS) persists in some positive airway pressure (PAP)-treated patients with obstructive sleep apnea (OSA). This study examined prevalence and severity of EDS in a real-world population with OSA to understand how EDS, PAP adherence, and patient satisfaction with care relate. METHODS: US residents (aged ≥18 years, self-reported diagnosis of OSA [from 1/1/2015 to 3/31/2020]) completed a survey in Evidation Health’s Achievement app assessing the Epworth Sleepiness Scale (ESS), PAP usage, and satisfaction with healthcare providers (HCPs) and overall OSA care. Patients were categorized by self-reported PAP use (nonuse [no PAP use], nonadherent [<4 h/night or <5 d/wk], intermediate [4-6 h/night, ≥5 d/wk], or highly adherent [≥6 h/night, ≥5 d/wk]; PAP-adherent refers to the intermediate and highly adherent groups). ESS >10 defined EDS. A linear model assessed relationship between PAP use and ESS score; a logistic regression model assessed the impact of PAP use and EDS on satisfaction with HCPs and overall OSA care. P-values are uncontrolled for multiplicity (nominal). RESULTS: In total, 2289 participants completed the survey (50.3% female; 82.5% White; mean±standard deviation [SD] age, 44.8±11.1 years; body mass index, 35.4±8.7 kg/m2). PAP use was: nonuse (n=700), nonadherent (n=153), or adherent (n=1436; intermediate n=225, high n=1211). Overall, 42.5% had EDS (ESS>10); mean (95% confidence interval [CI]) ESS scores were 14.1 (13.9, 14.3) in those with EDS and 6.7 (6.5, 6.8) in those without. The proportion (95% CI) with EDS per group were: nonuse (47% [43.7, 51.1]), nonadherent (52% [44.4, 60.2]), intermediate (53% [46.4, 59.4]), and highly adherent (36% [33.7, 39.1]). In a linear model (PAP users; n=1589), an additional h/night of PAP use was associated with lower ESS scores (β=–0.28; 95% CI=–0.40, –0.16; P<0.001). Overall, 72% were satisfied with HCPs and 65% with OSA care. Logistic regression (PAP users; n=1589) identified a positive association between PAP adherence (nonadherence=0, adherence=1) and satisfaction with HCPs (adjusted odds ratio [adjOR]=2.37; 95% CI=1.64, 3.43; P<0.001) and satisfaction with overall OSA care (adjOR=2.91; 95% CI=2.03, 4.17; P<0.001). EDS was associated with lower satisfaction with HCPs (adjOR=0.62; 95% CI=0.48, 0.80; P<0.001) and overall OSA care (adjOR=0.50; 95% CI=0.39, 0.64; P<0.001). CONCLUSIONS: In this real-world study, ESS scores decreased as PAP use increased, but EDS remained highly prevalent even among highly adherent patients. Adherence was associated with greater patient satisfaction with HCPs and overall care, whereas persistent EDS was associated with lower patient satisfaction with HCPs and overall OSA care. CLINICAL IMPLICATIONS: Strategies to improve patient satisfaction with OSA care should focus equally on PAP adherence and monitoring and resolution of residual EDS. DISCLOSURES: Employee relationship with Jazz Pharmaceuticals Please note: 2018-present Added 04/30/2021 by James Doherty, source=Web Response, value=Salary Consultant relationship with Evidation Health Please note: 08/2020-Present Added 05/03/2021 by Levon Eldemir, source=Web Response, value=Consulting fee Consultant relationship with Jazz Pharmaceuticals Please note: 08/2020 - Present Added 04/30/2021 by Benjamin Fox, source=Web Response, value=Consulting fee Employee relationship with Jazz Pharmaceuticals Please note: 2014 - current Added 04/13/2021 by Danielle Hyman, source=Web Response, value=Salary Stock Holder relationship with Jazz Pharmaceuticals Please note: 2014 - current Added 04/13/2021 by Danielle Hyman, source=Web Response, value=Ownership interest No relevant relationships by Nell Marshall, source=Web Response Employee relationship with Jazz Pharmaceuticals Please note: May 2018 to Present Added 05/05/2021 by Susan Morris, source=Web Response, value=Salary Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Salary Removed 04/13/2021 by Gregory Parks, source=Web Response Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Salary Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Ownership interest Employee relationship with Jazz Pharmaceuticals Please note: current Added 04/26/2021 by Gregory Parks, source=Web Response, value=Salary Employee relationship with Jazz Pharmaceuticals Please note: current Added 04/26/2021 by Gregory Parks, source=Web Response, value=stock options Consultant relationship with Jazz Pharmaceuticals, Inc. Please note: 2020-201 Added 04/29/2021 by Sairam Parthasarathy, source=Web Response, value=Consulting fee Employee relationship with Jazz Pharmaceuticals Please note: 11/1/2019 Added 05/02/2021 by Ragy Saad, source=Web Response, value=Stocks Consultant relationship with Jazz Pharmaceuticals Please note: 28 Aug 2020--Present Added 04/30/2021 by Jessica Schroeder, source=Web Response, value=Consulting fee Consultant relationship with Jazz Pharmaceuticals Please note: 08/2020 - Present Added 04/30/2021 by Mai Ka Ying Vang, source=Web Response, value=Consulting fee Removed 04/30/2021 by Mai Ka Ying Vang, source=Web Response Consultant relationship with Jazz Pharmaceuticals Please note: 08/2020 - Present Added 04/30/2021 by Mai Ka Ying Vang, source=Web Response, value=Consulting fee Employee relationship with Jazz Pharmaceuticals Please note: May 2020 Added 04/30/2021 by JERRY ZHANG, source=Web Response, value=Salary

Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration?

The first-choice therapy for adults with moderate/severe obstructive sleep apnea is continuous positive airway pressure (CPAP). However, studies evaluating whether the therapeutic CPAP level obtained from a titration is affected by sex are surprisingly scarce. Our main objective was to verify if sex influenced the optimal CPAP measurement obtained during a titration. This cross-sectional study was conducted in adults diagnosed with moderate/severe obstructive sleep apnea [baseline apnea-hypopnea index (AHI) ≥ 15.0 events/h] who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed) in a sleep laboratory setting. All participants used a nasal mask during the titration. The optimal pressure, leak, and residual AHI values were registered. Multiple linear regression was used to evaluate if clinical and polysomnographic data influenced the therapeutic CPAP level setting (95th percentile pressure). A total of 1,006 adults were enrolled: 354 women and 652 men. There were no statistically significant sex-related differences in the CPAP requirements and leak values delineated during the titration; all P-values > .005. However, the median residual AHI was significantly higher in males vs females: 2.7 events/h vs 2.2 events/h (P = .008). Body mass index (β: 0.292, P < .001), baseline AHI (β: 0.167, P < .001), and age (β: 0.065, P = .035) were independent predictors of the therapeutic CPAP level settings. Sex does not significantly influence the therapeutic CPAP settings. However, age, BMI, and baseline AHI emerge as independent predictors of the 95thpercentile CPAP requirement during an auto-adjusting CPAP titration. Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration? JClin Sleep Med. 2021;17(9):1815-1820.

The Relationship between Carotid Doppler Ultrasound and EEG Metrics in Healthy Preschoolers and Adults.

Despite widespread using electroencephalography (EEG) and Doppler ultrasound in pediatric neurology clinical practice, there are still no well-known correlations between these methods that could contribute to a better understanding of brain processes and development of neurological pathology. This study aims to reveal relationship between EEG and Doppler ultrasound methods. We compared two cohorts of adults and preschool children with no history of neurological or mental diseases. The data analysis included investigation of EEG and carotid blood flow indexes, which are significant in neurological diagnosis, as well as calculation of linear and non-linear EEG parameters and ratios between the systolic peak velocities of carotid arteries and carotid blood asymmetry. We have found age-dependent correlations between EEG and power Doppler ultrasound imaging (PDUI) data. Carotid blood flow asymmetry correlated with delta-rhythm power spectral density only in preschoolers. The ratios of blood flow velocities in the internal carotid arteries to those in the common carotid arteries correlated with higher peak alpha frequency and lower fractal dimension; moreover, they were associated with lower Epworth sleepiness scale scores. The study revealed significant correlations between EEG and PDUI imaging indexes, which are different for healthy children and adults. Despite the fact that the correlations were associated with non-clinical states such as overwork or stress, we assumed that the investigated parameters could be applicable for clinical trials.

1160 Improved Daytime Sleepiness Following Daily Morning Blue Light Therapy Is Associated With Altered Resting-state Network Connectivity

Abstract Introduction Light exposure, particularly blue wavelength light, has consistent positive effects on daytime sleepiness following mild traumatic brain injuries (mTBIs). While self-perceived improvements in daytime sleepiness are well-documented, the neurobiological underpinnings are not well understood. The purpose of this study was to localize changes in functional connectivity after daily morning blue light therapy (BLT) and to associate these changes with improvements in post-mTBI daytime sleepiness. Methods 29 individuals with a history of mTBI were randomized to receive either BLT (n=13) or placebo amber light (ALT; n=16). All participants self-reported daytime sleepiness (Epworth Sleepiness Scale (ESS); lower is better) and underwent resting-state functional magnetic resonance imaging at pre- and post-treatment. Whole-brain functional connectivity (FC) was estimated as the correlations between 400 cortical regions of interest (ROIs) assigned to 7 resting-state networks. A two-sample T-test for post-treatment ROI-to-ROI FC identified target connections (FDR corrected p&amp;lt;0.01). Post-treatment ESS scores and FC for these connections were correlated for treatment-related brain-behavior associations (uncorrected p&amp;lt;0.05). Results Lower FC after BLT in 4 ROI-to-ROI connections linking the default mode and visual networks was associated with lower ESS scores. Higher FC after BLT in 9 ROI-to-ROI connections linking attention, cognitive control, and visual networks was also associated with lower ESS scores. Conclusion BLT resulted in decreased self-reported daytime sleepiness, which was associated with decoupling of the default mode and visual networks as well as increased connectivity between and within attention and cognitive control networks, suggesting potentially improved attention to relevant stimuli and cognitive processes and less internal mentation. These associations may contribute to improved alertness, attention, and cognitive performance following a mTBI. Further work is needed to identify the optimal timing and dosage of BLT to maximize these outcomes. Support This study was funded by an award to Dr. Killgore from the US Army Medical Research and Materiel Command (USAMRMC; award number: W81XWH-14-1-0571).

Clinical significance of periodic limb movements during sleep: the HypnoLaus study

ObjectivePeriodic limb movements during sleep (PLMS) are prevalent in the general population, but their impact on sleep and association with cardiometabolic disorders are a matter of debate. MethodsData from 2162 participants (51.2% women, mean age 58.4 ± 11.1 years) of the population-based HypnoLaus study (Lausanne, Switzerland) were collected. Subjective sleep complaints and habits were assessed using the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale (ESS). Participants underwent a full polysomnography (PSG) at home and were evaluated for the presence of hypertension, diabetes, and metabolic syndrome. ResultsParticipants with a PLMS index (PLMSI) > 15/h (28.6% of the sample) had longer subjective sleep latency (18.6 ± 17.2 vs. 16.1 ± 14.3 min, p = 0.014) and duration (7.1 ± 1.2 vs. 6.9 ± 1.1 h, p < 0.001) than participants with PLMSI ≤ 15/h. At the PSG, they spent more time in stage N2 sleep (49.0 ± 11.2 vs. 45.5 ± 9.8%, p < 0.001), less in stage N3 (17.6 ± 8.2 vs. 20.6 ± 8.4%, p < 0.001) and in REM sleep (20.3 ± 6.4 vs. 22.4 ± 6.0%, p < 0.001), and exhibited longer REM latency (104.2 ± 70.2 vs. 91.7 ± 58.6 min, p < 0.001) and higher arousal index (26.5 ± 12.3 vs. 19.2 ± 9.7 n/h, p < 0.001). Participants with a PLMSI > 15/h had a lower ESS scores and higher prevalence of hypertension, diabetes, and metabolic syndrome. Multivariate analysis adjusting for confounding factors confirmed the independent association of PLMSI > 15/h with subjective sleep latency and duration, and with objective sleep structure disturbances. However, the associations with sleepiness and cardiovascular risk factors disappeared. ConclusionsIn our large middle-age European population-based sample, PLMSI > 15/h was associated with subjective and objective sleep disturbances but not with sleepiness, hypertension, diabetes, or metabolic syndrome.

The influence of hypertension on daytime sleepiness in obstructive sleep apnea

Daytime sleepiness is a common symptom among hypertensive patients. The aim of this study was to determine subjective sleepiness assessed by Epworth Sleepiness Scale (ESS) and to asses sleep architecture in 304 patients with arterial hypertension. All patients underwent a standardized diagnostic overnight, polysomnography. The control group consisted of 67 normotensives. The hypertensive patients had a decreased sleep efficiency, mean and minimum oxygen saturation levels, and increased apnea/hypopnea index and oxygen desaturation index compared with normotensive patients. The lower ratio of N3 sleep, higher of N2 sleep, and decreased sleep efficiency was observed in hypertensives without obstructive sleep apnea (OSA). In the moderate to severe OSA groups, the total ESS score was significantly lower in hypertensives compared with normotensives. The ESS scores decreased with age in hypertensives, but not in normotensives. The study showed that ESS total score is lower in hypertensives than in normotensives with OSA, making the OSA more difficult to suspect. Thus, the low ESS score in hypertensives should not discourage further evaluation.

Patients' preference of established and emerging treatment options for obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is the most common form of sleep-disordered breathing. The standard treatment, continuous positive airway pressure (CPAP), has limited long-term compliance. Alternative treatment options are required and new methods, including hypoglossal nerve stimulation (HNS) and continuous transcutaneous electrical stimulation (CTES), are currently emerging. We report on patients' preference for different treatments of OSA. We recorded patients' age, gender, body mass index (BMI), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire with 10 questions (FOSQ10), severity of OSA, and current treatment. We showed pictures of existing [CPAP, mandibular advancement device (MAD)] and emerging treatments (HNS and CTES). We then asked (I) whether participants were interested in further information about HNS/CTES; (II) if they would be willing to try HNS/CTES; and (III) if they were to choose only one of the four listed treatments, which one would they prefer to use every night. One hundred sixty-two patients completed the survey {81 males, mean age 52 [12] years, BMI 34 [7] kg/m(2), ESS 10.2 (6.0) points, FOSQ10 28.5 (8.1) points}. The majority of the respondents (89.5%) had been diagnosed with OSA. A total of 91.3% of the respondents were interested in more information and were willing to try HNS/CTES. Most respondents preferred the potential use of CTES (56.7%), while 21.7% chose HNS, 17.8% CPAP, and 3.8% the MAD. There were no differences in the characteristics of the patients who preferred CTES compared to those who preferred other treatments, but a regression analysis revealed that a low ESS score was an independent predictor of patients choosing CTES (P<0.05). More than 9 out of 10 of the respondents were interested in trying emerging technologies to treat OSA, most preferring CTES. Less sleepy patients were more likely to choose less invasive treatments. These findings will likely impact on future research and development of therapies for sleep-disordered breathing.

P295 Patients' Preference Of Established And Emerging Treatments For Obstructive Sleep Apnoea

Background Obstructive sleep apnoea (OSA) is the most common form of sleep-disordered breathing, and the standard treatment is continuous positive airway pressure (CPAP). Emerging treatments for OSA, including electrical hypoglossal nerve stimulation (HNS) and non-invasive electrical stimulation (nES), are currently being developed. To involve patients in the development of research projects, we evaluated patients’ preference for different treatments of OSA using a short survey. Patients and methods We recorded patients’ age, gender, body-mass-index (BMI), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ10), severity of OSA, and current treatment. We showed pictures of existing (CPAP, mandibular advancement device (MAD)) and emerging treatments (HNS and nES). We then asked 1) whether they were interested in further information about HNS/nES, 2) if they would be willing to try HNS/nES, and 3) if they were to choose only one of the four listed treatments, which one would they prefer to use every night. Results 162 patients completed the survey (81 males, mean age 52 (12) years, BMI 34 (7.3) kg/m2, ESS 10.2 (6.0) points, FOSQ10 28.5 (8.1) points). The majority of the respondents (89.5%) had been diagnosed with OSA, with 95.4% of those being treated with CPAP. 91.3% of the respondents were interested in more information and were willing to try HNS/nES. Most respondents preferred the potential use of nES (56.7%), while 21.7% chose HNS, 17.8% CPAP, and 3.8% the MAD. There were no differences in the characteristics of the patients who preferred nES compared to those who preferred other treatments; however, a regression analysis showed that a low ESS score was a predictor of patients choosing nES (p Conclusion Although the CPAP is the established treatment for OSA, most patients would prefer alternatives for long-term treatment. The majority of the respondents were interested in emerging technologies, with less sleepy patients more likely to choose less invasive treatment options.

Long-Term Therapy with Continuous Positive Airway Pressure in Obstructive Sleep Apnea: Adherence, Side Effects and Predictors of Withdrawal – A ‘Real-Life’ Study

Background: Long-term adherence to positive airway pressure (PAP) treatment is essential in patients with obstructive sleep apnea syndrome (OSAS). Objectives: The aim of the present study was to analyze treatment adherence under real-life conditions and factors associated with discontinuation of PAP therapy. Methods: Patients newly diagnosed with OSAS and started on PAP therapy were contacted by telephone after a minimum of 1 year. Side effects, quality of life, subjective treatment adherence and Epworth Sleepiness Scale (ESS) scores were assessed. Objective treatment adherence was calculated by reading the built-in run time counter of the PAP device. Anthropometric parameters, level of education, apnea-hypopnea index (AHI), ESS score and the type of PAP therapy prescribed at the time of the first stay in the sleep lab were collected retrospectively. Results: Median follow-up was 13 months (range 7–18 months). Of 303 patients (69 female, 234 male) available for this study, 191 patients (63%) still used the PAP device regularly (‘users’), while 83 (27.4%) had definitively discontinued PAP treatment (‘nonusers’). In the nonusers group, 29 patients (34.9%) discontinued PAP treatment within the first 3 months. In the users group, subjective PAP usage was 6.6 ± 1.5 h/night and objective adherence was 4.7 ± 2.3 h/night. Objective nightly use of PAP treatment correlated significantly with baseline AHI (r = 0.13, p = 0.041) but not with sex, age, body mass index, ESS score or education level. Patients with a low AHI and ESS score and patients without a coexisting medical condition or with more than two comorbidities tended to discontinue PAP therapy more frequently. Conclusions: PAP treatment adherence has to be optimized in OSAS patients. When initiating PAP therapy, clinicians have to focus on those patients at risk for discontinuing treatment. Education sessions and closer follow-up are possible strategies to improve treatment adherence and to avoid treatment discontinuation.

Repeating administration of Epworth Sleepiness Scale is clinically useful

We aimed to verify whether it is clinically useful to repeat the Epworth Sleepiness Scale (ESS) in individuals with suspected sleep-disordered breathing (SDB). In this cross-sectional, prospective study, results of the repeated administration of the ESS were analyzed. In 929 consecutive patients, ESS was obtained as usual in the laboratory routine, immediately before the sleep study (ESS1) and was repeated in the morning, after the polysomnography (ESS2). ROC curve, classical psychometry, and item response theory (IRT) Rasch analysis were used to assess measurement properties of ESS. The ESS1 score was (mean ± SD), 11 ± 5.1, and the ESS2, 13 ± 4.7 (p < 0.001). Change in ESS score is explained in multivariate analysis by age, but not by gender, educational level, change in Stanford Sleepiness Scale, symptoms of sleep disorder, or polysomnography results. Accuracy of an ESS score >10 to predict apnea-hypopnea index ≥5 increased from 56% (ESS1) to 72% (ESS2). IRT psychometric properties (unidimensionality, invariance, local independence) were maintained in ESS2. Repeating the administration of the Epworth Sleepiness Scale in a clinical setting increases its score and diagnostic accuracy and correlation with SDB variables, without changing the psychometric properties of the scale. This experiment indicates the clinical usefulness of repeating the ESS. The scale can be repeated at a negligible cost, before dismissing individual patients on the basis of a low ESS score, discontinuing a potentially lifesaving diagnostic and therapeutic process.

Dissociation of Obstructive Sleep Apnea From Hypersomnolence and Obesity in Patients With Stroke

Obstructive sleep apnea (OSA) is seldom considered in the diagnostic investigation in the poststroke period although it is a stroke risk factor and has adverse prognostic implications after stroke. One reason might be that widely used clinical criteria for detection of OSA in the general community are not applicable in patients with stroke. We hypothesized that patients with stroke report less sleepiness and are less obese than subjects from a community sample with the same severity of OSA. We performed polysomnography in 96 consecutive patients with stroke admitted to a stroke rehabilitation unit and in a community sample of 1093 subjects without a history of stroke. We compared the degrees of subjective sleepiness assessed by the Epworth Sleepiness Scale and body mass index between the 2 samples according to OSA categories assessed by the frequency of apneas and hypopneas per hour of sleep (<5, no OSA; 5 to <15 mild OSA; and >or=15, moderate to severe OSA). Compared with the community sample, patients with stroke with OSA had significantly lower Epworth Sleepiness Scale scores and body mass index for mild OSA (Epworth Sleepiness Scale 9.3+/-0.3 versus 5.6+/-0.5, P<0.001 and body mass index 33.1+/-0.5 versus 28.5+/-1.1, P<0.048) and for moderate to severe OSA (Epworth Sleepiness Scale 9.7+/-0.4 versus 7.1+/-0.9, P=0.043 and body mass index 36.4+/-0.8 versus 27.2+/-0.8 kg/m(2), P<0.025). For a given severity of OSA, patients with stroke had less daytime sleepiness and lower body mass index than subjects without stroke. These factors may make the diagnosis of OSA elusive in the poststroke period and preclude many such patients from the potential benefits of OSA therapy.

Using Modafinil to Treat Fatigue in Parkinson Disease

Fatigue is a major nonmotor symptom in Parkinson disease(PD). It is associated with reduced activity and lower quality of life. To determine if modafinil improves subjective fatigue and physical fatigability in PD. Nineteen PD patients who reported significant fatigue in the Multidimensional Fatigue Inventory (MFI) participated in this 8-week study. Subjects took their regular medications and were randomly assigned to the treatment group (9 subjects, modafinil 100-mg capsule BID) or placebo group (10 subjects). We used the MFI to measure subjective fatigue and used finger tapping and intermittent force generation to evaluate physical fatigability. Subjects also completed the Epworth Sleepiness Scale (ESS) and the Center of Epidemiological Study-Depression Scale. There were no significant differences at baseline and at 1 month in finger tapping and ESS between the modafinil and placebo groups. At 2 months, the modafinil group had a higher tapping frequency (P<0.05), shorter dwell time (P<0.05), and less fatigability in finger tapping and tended to have lower ESS scores (P<0.12) than the placebo group. However, there was no difference between groups over time for any dimension of the MFI . This small study demonstrated that although modafinil may be effective in reducing physical fatigability in PD, it did not improve fatigue symptoms.

Narcolepsy with long sleep time: a specific entity?

The classical narcolepsy patient reports intense feelings of sleepiness (with/out cataplexy), normal or disrupted nighttime sleep, and takes short and restorative naps. However, with long-term monitoring, we identified some narcoleptics resembling patients with idiopathic hypersomnia. To isolate and describe a new subtype of narcolepsy with long sleep time). University Hospital Controlled, prospective cohort Out of 160 narcoleptics newly diagnosed within the past 3 years, 29 (18%) had a long sleep time (more than 11 h/24 h). We compared narcoleptics with (n = 23) and without (n = 29) long sleep time to 25 hypersomniacs with long sleep time and 20 healthy subjects. Patients and controls underwent face-to face interviews, questionnaires, human leukocyte antigen (HLA) genotype, an overnight polysomnography, multiple sleep latency tests, and 24-h ad libitum sleep monitoring. Narcoleptics with long sleep time had a similar disease course and similar frequencies of cataplexy, sleep paralysis, hallucinations, multiple sleep onset in REM periods, short mean sleep latencies, and HLA DQB1*0602 positivity as narcoleptics with normal sleep time did. However, they had longer sleep time during 24 h, and higher sleep efficiency, lower Epworth Sleepiness Scale scores, and reported their naps were more often unrefreshing. Only 3/23 had core narcolepsy (HLA and cataplexy positive). The subgroup of narcoleptics with a long sleep time comprises 18% of narcoleptics. Their symptoms combine the disabilities of both narcolepsy (severe sleepiness) and idiopathic hypersomnia (long sleep time and unrefreshing naps). Thus, they may constitute a group with multiple arousal system dysfunctions.

Gender Differences in the Clinical Characteristics Among Japanese Patients With Obstructive Sleep Apnea Syndrome

Gender differences in the prevalence of various manifestations of obstructive sleep apnea syndrome (OSAS) is not as great as previously believed. The aim of the present study was to clarify the clinical patient characteristics of Japanese women and men with OSAS. A cross-sectional case-match control study was performed on patients from two sleep disorder centers. Two hundred forty-five women with OSAS were classified into premenopausal (n = 70) and postmenopausal (n = 175) groups. As well, 245 men matched for both age and apnea-hypopnea index (AHI) and another 245 men matched for age and body mass index (BMI) were established. We compared descriptive variables between genders in both the premenopausal and the postmenopausal female patient groups. As a whole, female patients had significantly higher BMI than AHI-matched male patients (p < 0.05) and a significantly lower value of AHI than BMI-matched male patients (p < 0.001). Female patients had lower Epworth Sleepiness Scale scores than BMI-matched male patients (p < 0.05). On logistic regression analysis, presence of hypertension was significantly associated with BMI (>or=25 kg/m(2)), AHI (>or= 15 to < 30 events/h; >or= 30 to < 60 events/h; >or= 60 events/h), and presence of both hyperlipidemia and diabetes mellitus. However, gender differences were not associated with the occurrence of hypertension. Female patients had significantly lower optimal levels of continuous positive airway pressure than male patients. Our results suggest that both the OSAS severity and the strength of pharyngeal closure is less in Japanese female patients than in male patients. Moreover, Japanese female patients are thought to have less daytime sleepiness than male patients but a similar rate of hypertension as male patients.

Mexican Version of the Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) has been reputed as a quick, valid, and reliable method to assess Daytime sleepiness (DS). Since its publication, it has been translated into a number of languages. Our aim was to determine valid- ity and reliability indicators of an Spanish language version ESS for Mexican population. Considering that in developing countries the majority of persons use public transportation, validity and reliability indicators were also assessed utilizing the ESS without item 8. ESS was applied to a Group of college students (GCS), a selected group of Healthy subjects (HS), and a Group of patients with Sleep disorders (GPSD). We made an ESS comparison among the 3 groups, calculated the correlation between the ESS and the Multiple Sleep Latency Test (MSLT) and determined construct validity and internal consistency. GCS and GHS had lower ESS scores than GPSD. Regarding convergence validity, we obtained a negative correlation between the ESS and the MSLT; we also found a rise in the ESS score associated with an increase in the Ap- nea-hypopnea index (AHI). With respect to construct validity (employing main component analysis and varimax rotation), we found that one factor explains 52.01% of variance. We determined that the ESS internal consistency was 0.85. When item eight was suppressed, validity and reliability remained acceptable. The present ESS Spanish-language exhibited suit- able levels of validity and reliability. Use of the ESS, suppressing item eight, allows assessment of DS more accurately in individuals who do not travel by automobile on a regular basis.

Excessive daytime sleepiness in patients with depressive disorder

To evaluate excessive daytime sleepiness in patients with depressive disorder and to examine its association with the severity of depression and suicidal ideation. Seventy patients were interviewed and assessed by the Epworth Sleepiness Scale (ESS), the Beck Depression Inventory (BDI) and the Beck Scale for Suicidal Ideation (SSI). Descriptive analysis, Pearson correlations and Student's t-test were used for data analyses. Most of the patients (57.1%) obtained high scores on the ESS. Correlation was positive and strongly significant between ESS scores and BDI scores, as well as between ESS scores and SSI scores. Patients with high ESS scores obtained higher mean BDI and SSI scores in comparison to patients with lower ESS scores. Significant differences (p < 0.05) were encountered when the patients with higher (> or = 10) and lower (< 10) ESS scores were compared in terms of total ESS, BDI and SSI scores. Excessive daytime sleepiness was frequent among patients and significantly associated with higher levels of depression and particularly with suicidal ideation. Thus, a careful investigation of daytime sleepiness in depressed patients is required during clinical evaluation.