Persistent Excessive Daytime Sleepiness Research Articles

Prognostic Factors Related to Sleep Quality in Patients With Obstructive Sleep Apnea After Positive Airway Pressure Therapy

Background and Objectives: This study aimed to evaluate the factors that influence deep sleep restoration in patients with obstructive sleep apnea (OSA) following positive airway pressure (PAP) therapy.Methods: In total, 363 patients diagnosed with OSA who received PAP therapy over at least 3 months were enrolled in the study. Polysomnographic parameters, anatomical characteristics, and subjective sleep-related parameters were evaluated according to the presence of daytime sleepiness and morning headache before and after 3 months of PAP treatment.Results: Age was significantly different according to whether excessive daytime sleepiness (EDS) was alleviated (average: 49.35 years) or persisted (average: 52.82 years) (p=0.001). Age was also significantly associated with morning headache (p=0.037). Body mass index (BMI) was higher in the alleviated EDS group (28.70 kg/m<sup>2</sup>) than in the persistent EDS group (27.13 kg/m<sup>2</sup>; p=0.002). The apnea-hypopnea index (AHI) was correlated with the EDS outcome (p=0.011). The group with alleviated EDS had a longer mandibular plane to hyoid distance (MPH) than the group with persistent EDS (17.95 mm vs. 15.38 mm; p<0.001). However, BMI, AHI, and MPH showed no significant associations with morning headache. Epworth Sleepiness Scale scores were higher in the alleviated EDS and alleviated morning headache groups (EDS: p<0.001, morning headache: p=0.001). Self-Efficacy Measure for Sleep Apnea (SEMSA) values differed significantly between the EDS groups (p<0.001), but not between the morning headache groups (p=0.122). After 3 months of PAP therapy, the MPH was negatively correlated with EDS in univariate (odds ratio [OR]=0.921, p<0.001) and multivariate analyses (OR=0.937, p=0.028). The SEMSA score was also negatively correlated with EDS in univariate (OR=0.961, p<0.001) and multivariate (OR=0.973, p=0.019) analyses.Conclusion: Age, polysomnographic metrics, and anatomical considerations were important for sleep quality-associated daytime symptoms. In addition, anatomical characteristics and the patient’s self-efficacy were significantly associated with the effect of PAP treatment on sleep quality.

1005 The hunt for solutions to daytime sleepiness in the setting of treated obstructive sleep apnea

Abstract Introduction There is a possible association between OSA and vitamin D deficiency (Neighbors 2018). Vitamin D deficiency is associated with fatigue and excessive daytime sleepiness (EDS) (Bouloukaki 2022). Vitamin D deficiency might play a role in the residual fatigue or sleepiness seen in some patients with treated OSA. Report of case(s) We present a 28 year old female with RLS, anxiety and mild OSA with persistent daytime fatigue and sleepiness despite optimal treatment of OSA. She was evaluated for OSA via a HST due to symptoms of snoring, overnight awakenings, non-restorative sleep, and EDS (Epworth Sleepiness Scale (ESS) of 11/24). The HST revealed mild OSA (REI 4% of 11). Bloodwork revealed a ferritin of 31 ng/mL. She was treated with autoPAP 5-15 cm and daily ferrous sulfate 325 mg. At follow-up she reported significant improvement in her RLS. Repeat ferritin level was 59 ng/ml and continued iron supplementation was recommended. Despite 98% (40/41 days) compliance and effective treatment of OSA with residual AHI of 0.9, she continued to report persistent daytime fatigue and EDS. Given the residual symptoms we checked a vitamin D level which was reduced at 7 ng/mL (21-100 ng/mL). Conclusion We identified in the sleep medicine literature a case report of a 28 yo patient with EDS who had significant improvement in symptoms after her vitamin D deficiency (5.9 ng/mL) was treated. This woman had improvement in her ESS from 10/24 to 1/24 (McCarty 2010). This patient, however, did not have OSA which was the case with our patient. This report speculated that a possible mechanism for clinical improvement could include enhanced sleep quality due to resolution of hypovitaminosis D-associated non-inflammatory myopathy, or a possible immunomodulatory effect of vitamin D decreasing central nervous system homeostatic sleep pressure. Residual fatigue and EDS in the treatment of OSA may have multiple causes for which a comprehensive approach can help identify and treat the underlying cause. Support (if any) Vitamin D and obstructive sleep apnea: a systematic review and meta-analysis(Neighbors 2018) Vitamin D levels in primary care patients: correlations with clinical, seasonal, and quality-of-life parameters(Bouloukaki 2022) Resolution of Hypersomnia Following Identification and Treatment of Vitamin D Deficiency(McCarty 2010)

0858 Under reporting of Apnea Hypopnea Index (AHI) in patients with predominant REM sleep disordered breathing on antidepressants

Abstract Introduction The prevalence of Rapid Eye Movement (REM) related Sleep Disordered Breathing (SDB) ranges from 13.5% to 36.7% in patients suspicious to have SDB.1 It is reported that patients with REM related SDB often have associated depression and are commonly on anti-depressants.2 Antidepressants suppress overall REM sleep duration. Significant sleep disordered breathing is known to occur during REM sleep. These patients commonly present with excessive daytime sleepiness and fatigue. Obstructive sleep apnea (OSA) diagnosis is often missed in these patients secondary to REM sleep suppression and subsequent underreporting of AHI.1. Conwell W, Patel B etal 2012 PMID: 21614575. 2. Geckil AA, Ermis H. 2020 PMID: 30949927. Report of Cases: Case 1 is a 53-year-old obese white female with stable depression on citalopram 20mg presented with witnessed loud snoring and apneas, sleep onset and maintenance insomnia, daytime fatigue and hypersomnolence. Her Epworth Sleep Score (ESS) was 13/24. Her in lab baseline polysomnogram demonstrated overall AHI 3.8/hour and REM only AHI 24.3/hour. To further explore her persistent daytime sleepiness a Mean Sleep Latency Test (MSLT) was ordered. Citalopram was held 2 weeks prior to MSLT. In the PSG her overall AHI increased to 7.6/hour diagnosing her with mild OSA. PAP therapy was initiated that improved patients nocturnal sleep, daytime fatigue and hypersomnolence. Case 2 is a 54-year-old overweight white female with past medical history of chronic stable depression on Wellbutrin SR 100 mg daily presented with significant day time fatigue and hypersomnolence (ESS 15/24). Her baseline PSG reported AHI 1.7/hour with REM only AHI 10.7/hour. However due to persistent excessive daytime sleepiness MSLT was ordered. Her Wellbutrin was held 2 weeks prior to testing. Her overnight PSG demonstrated increase in her AHI to 7.9/hour and REM AHI to 34.2/hour. Mild obstructive sleep apnea was diagnosed, and PAP therapy was initiated that improved her hypersomnolence. Conclusion These cases illustrate that antidepressants likely mask obstructive sleep apnea by suppressing REM sleep. Given the underreported AHI in patients with REM SDB who are on anti-depressants it may be prudent to hold anti-depressants for 2 weeks to establish an accurate diagnosis of sleep apnea. Support (If Any)

Early objective adherence to hypoglossal nerve stimulation therapy.

To assess early adherence to therapy with hypoglossal nerve stimulation therapy. This is a prospective study of consecutive patients with moderate to severe obstructive sleep apnea who underwent implantation of hypoglossal nerve stimulation therapy within a single academic practice and attended a follow-up appointment after greater than 30 days of therapy use. Objective adherence data were extracted from an objective monitoring database and compared to patient characteristics. The study population was 79 participants who were 29.1% female with a mean age of 58.7 ± 12.8 years old, body mass index of 28.9 ± 3.4 kg/m2, and baseline apnea-hypopnea index of 33.8 ± 17.6 events/h. In the first 7 days after device activation, average use was 7.8 h/night, with 91.9% of nights with greater than 4 hours of therapy use and an average of 0.2 pauses in therapy per night. These figures remained stable after 30 days of use: 7.7 h/night, 91.0% of nights longer than 4 hours, and 0.3 pauses per night. Objective evidence of difficulty with acclimatization was associated with age less than 60 years (odds ratio 2.8, 95% confidence interval 1.1-7.1, P = .03) and a history of prior upper airway surgery (3.9, 1.2-11.9, P = .015). Insomnia was present in 31 patients and was not associated with objective evidence of difficulty tolerating therapy. Early adherence to hypoglossal nerve stimulation is excellent (92.4% >4 hours on >70% of nights), suggesting that the acclimatization period is straightforward in most. Younger age and a history of prior upper airway surgery appear to be associated with an increased risk of difficulty with acclimatization. Huyett P. Early objective adherence to hypoglossal nerve stimulation therapy. J Clin Sleep Med. 2022;18(2):631-636.

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. 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Associations of frequent pain symptoms with excessive daytime sleepiness in adolescents: a longitudinal study.

Pain symptoms, sleep disturbance, and daytime sleepiness are common in adolescents. This study examined the cross-sectional and prospective associations between pain symptoms and excessive daytime sleepiness (EDS) in a large sample of adolescents. Participants were 7,072 adolescents (mean age = 14.58 years) in a follow-up study of behavior and health in Shandong, China. A self-administered structured questionnaire was used to assess pain symptoms (headache, stomachache, and other general pain), body weight and height, sleep, anxiety/depression, substance use, and family environment in November-December in 2015 and 1 year later. The Chinese adolescent daytime sleepiness scale was used to measure daytime sleepiness. Of the sample, 19.8% and 23.2% had moderate or severe EDS at baseline and at 1-year follow-up, respectively. The prevalence and 1-year incidence rates of EDS significantly increased with the frequencies of pain symptoms. Frequent pain was significantly associated with increased risk of EDS at baseline (odds ratio = 2.01, 95% confidence interval = 1.56-2.59), incident EDS (odds ratio = 1.41, 95% confidence interval = 1.03-1.93), and persistent EDS (odds ratio = 2.17, 95% confidence interval = 1.52-3.09) while adjusting for adolescent and family covariates, including anxiety/depression, nocturnal sleep duration, insomnia symptoms, frequent snoring, body mass index, and hypnotic use. Similar associations were observed across headache, stomachache, and other pain. Frequent pain is significantly and independently associated with increased risk of EDS. Our findings suggest that assessing and treating pain symptoms is important to improve healthy sleep and reduce risk of EDS in adolescents. Further research is needed to understand the underlying psychological and neurobiological mechanisms between pain and daytime sleepiness in adolescents. Liu X, Liu Z-Z, Yang Y, Jia C-X. Associations of frequent pain symptoms with excessive daytime sleepiness in adolescents: a longitudinal study. J Clin Sleep Med. 2021;17(12):2415-2423.

Correlation between the Epworth Sleepiness Scale and the Maintenance of Wakefulness Test in Obstructive Sleep Apnea Patients Treated with Positive Airway Pressure

BackgroundThe Epworth sleepiness scale (ESS) is often used to evaluate the impact of treatment in patients with obstructive sleep apnea hypopnea syndrome (OSA). We aimed to evaluate the correlation between ESS and the Maintenance of Wakefulness Test (MWT) in a population of OSA patients treated with positive airway pressure (PAP). MethodsWe retrospectively included all patients during a 2-year period who were diagnosed with OSA in our sleep clinic and required PAP therapy. ESS was evaluated at baseline and after PAP therapy for all patients, and all had a concomitant MWT. Correlation between final ESS, change in ESS, and MWT were evaluated using Spearman's correlation. Given that MWT is considered as the gold standard, the diagnostic performance of ESS was evaluated against MWT. ResultsHundred thirty-four OSA patients were included. At the time of MWT, 89.6% of the patients were compliant (PAP use ≥4hours/night), and only 9 (6.7%) had persistent sleepiness despite PAP treatment (mean sleep latency at MWT<19.4min). Moderate correlation was observed between final ESS and MWT (Spearman's correlation coefficient=-0.42), but no correlation was found between change in ESS and MWT. Diagnostic performance was as follows for final ESS: sensitivity=55.6%, specificity=84.8%, PPV=20.8%, and NPV=96.4%. ConclusionsESS was moderately correlated with MWT in a population of OSA patients compliant with PAP therapy. In this population, ESS showed poor diagnostic performance in identifying patients with persistent excessive daytime sleepiness. ClinicalTrials.gov IdentifierNCT03629834.

Risk factors of excessive daytime sleepiness in a prospective population-based cohort.

Although excessive daytime sleepiness is commonly evaluated in clinical and research settings using the Epworth Sleepiness Scale, few studies have assessed the factors associated with its incidence in the general population. We prospectively investigated the predictors of incident and persistent excessive daytime sleepiness in 2,751 subjects (46.1% men, mean age 56.0±9.8years) from the CoLaus-PsyCoLaus population-based cohort (Lausanne, Switzerland) over 5years. Participants completed the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index, and underwent a full clinical evaluation at baseline and 5 years afterwards. Ambulatory polysomnography was performed at baseline in a sub-sample of 1,404 subjects. Among the 2,438 subjects without excessive daytime sleepiness (Epworth Sleepiness Scale ≤10) at baseline, the 5-year incidence of excessive daytime sleepiness was 5.1% (n=124). Multivariate logistic regression revealed that male sex, depressive symptoms, reported poor sleep quality and moderate to severe obstructive sleep apnea were independent predictors of incident excessive daytime sleepiness, while older age, moderate coffee consumption, periodic leg movement during sleep and hypertension were independent protective factors. Stratified analysis according to sex and age showed some distinctive associations. Among the 313 patients with excessive daytime sleepiness at baseline, 137 (43.8%) had persistent excessive daytime sleepiness 5years later. Our findings provide new insights into the predictors of incident excessive daytime sleepiness, but interventional studies are needed to understand the impact of treating these risk factors on the incidence of excessive daytime sleepiness.

A 3-year observation of excessive daytime sleepiness after subthalamic deep brain stimulation in patients with Parkinson’s disease

ObjectiveSubthalamic nucleus deep brain stimulation (STN DBS) has a positive effect on sleep quality, but its effect on wake functions is controversial. This study evaluated the longitudinal changes of the quality of sleep and excessive daytime sleepiness (EDS) in Parkinson’s disease (PD) patients undergoing STN DBS and identify which factors are associated with the presence of EDS before and after STN DBS. Patient and methodsA total of 33 PD patients who underwent bilateral STN DBS between July 2011 and October 2015 were recruited. We evaluated subjective sleep quality assessed by Parkinson’s Disease Sleep Scale (PDSS) and EDS using Epworth Sleepiness Scale (ESS) preoperatively and 6 months, 1 year, and 3 years postoperatively. ResultsThere is a significant improvement in PDSS, and a noticeable change occurs immediately after the surgery. After DBS, the number of patients with persistent EDS gradually decreased, but patients with newly developed EDS were added. Baseline ESS score was highly correlated with EDS at 6 months and 1 year postoperatively, and older age of PD onset was highly associated with EDS at 1 year after DBS. At 3 years after DBS, the total PDSS score is a main contributing factor for EDS. There was no significant difference in dopamine agonist dose (agonist LED) and levodopa equivalent daily dose (LEDD) between groups with and without EDS at any time points. ConclusionBilateral STN DBS improves the subjective sleep quality, but EDS may improve or worsen. The risk factors for EDS change over time after STN DBS. Interestingly, dopaminergic medication did not affect EDS in DBS-treated PD patients.

Natural history of excessive daytime sleepiness: a population-based 5-year longitudinal study.

To document the rates of persistent, remitted, and intermittent excessive daytime sleepiness (EDS) in a longitudinal 5-year community study of adults and to assess how changes in risk factors over time can predict improvement of daytime sleepiness (DS). Participants were recruited in 2007-2008 as part of a population-based epidemiological study implemented in Canada. They completed postal assessments at baseline and at each yearly follow-up. An Epworth Sleepiness Scale total score >10 indicated clinically significant EDS; a 4-point reduction between two consecutive evaluations defined DS improvement. Socio-demographic, lifestyle, health characteristics, and sleep-related measures (e.g. insomnia symptoms, sleep duration, sleep medication) were self-reported at each time point. Cox proportional-hazard models were used to predict EDS and DS remissions over 5 years. Among the 2167 participants, 33% (n = 714) met criteria for EDS at baseline, of whom 33% had persistent EDS, 44% intermittent EDS, and 23% remitted EDS over the follow-up. Furthermore, 61.4% of 2167 initial participants had stable DS, 27.1% sustained DS improvement and 8.5% transient improvement over the follow-up. The main predictors of EDS remission or DS improvement were normal weight, taking less hypnotics, having hypertension, increased nighttime sleep duration, and decreased insomnia, and depressive symptoms. EDS waxes and wanes over time with frequent periods of remission and is influenced by behavioral characteristics and changes in psychological, metabolic, and nighttime sleep patterns. Targeting these predictors in future interventions is crucial to reduce DS in the general adult population.

Residual excessive daytime sleepiness in patients with obstructive sleep apnea treated with positive airway pressure therapy.

Patients with obstructive sleep apnea (OSA) commonly report residual excessive daytime sleepiness (EDS) despite treatment with positive airway pressure (PAP). The present study aimed to determine whether patients presenting with subjective sleepiness after treatment with PAP therapy had objective evidence of residual sleepiness. We conducted a retrospective analysis of 29 adults with OSA on PAP therapy who underwent a standardized evaluation for EDS. Patients were evaluated with the Epworth Sleepiness Scale (ESS) and attend an in-lab polysomnogram (PSG) with PAP followed by a multiple sleep latency test (MSLT). Our cohort consisted of 23 men (79%) and 6 women (21%) with a mean age of 40.7years. All patients were subjectively sleepy with an ESS score of > 10 and met minimal PAP usage of 4h a night for at least 70% of nights with a residual apnea-hypopnea index (AHI) ≤ 10. On MSLT, 31% of patients had an average sleep onset latency (SOL) < 8min, 35% had a SOL between 8 and 11min, and 35% had SOL > 11min. After optimizing PAP therapy and sleep in patients with OSA and residual EDS, the majority were found to have objective findings of an abnormally short SOL on MSLT. This is further evidence that there is a distinct OSA phenotype that will have persistent EDS despite appropriate treatment of their sleep-disordered breathing. Objective testing to quantify the degree of sleepiness is recommended for OSA patients with residual EDS.

Obstructive sleep apnea and self-reported functional impairment in revascularized patients with coronary artery disease in the RICCADSA trial.

Daytime sleepiness, a frequent symptom of obstructive sleep apnea (OSA), can impact functional status. In patients with coronary artery disease (CAD) and concomitant OSA, the distinction between sleep-related functional impairment from underlying CAD versus OSA is unclear. This study evaluated the impact of OSA on sleep-related functional impairment in patients with CAD and compared the effect of 1-year continuous positive airway pressure (CPAP) use on change in impairment between those with and without excessive daytime sleepiness (EDS) and OSA. We hypothesized that sleep-related functional impairment is impacted by EDS independent of OSA in patients with CAD. One hundred five CAD patients without OSA and 105 with moderate-to-severe OSA from the RICCADSA trial were matched on disease severity and included in the current substudy. Of those with OSA, 80 were allocated to CPAP. Functional Outcomes of Sleep Questionnaire (FOSQ) score < 17.9 corresponded to sleep-related functional impairment. Following revascularization, CAD patients with and without OSA frequently report sleep-related functional impairment (35% and 27.3%, respectively; p = .29). Moderate-to-severe OSA was not related to baseline FOSQ scores < 17.9 in regression analyses; EDS was (OR 4.82, 95% CI 2.12-11.0; p < .001). CPAP use significantly improved FOSQ scores from baseline to 1-year follow-up in OSA patients with EDS (17.2 ± 2.0 to 18.15 ± 1.7, p = .002) despite suboptimal adherence. Sleep-related functional impairment may be reflective of persistent EDS, independent of OSA. Diagnosing OSA and initiating treatment are worthwhile in individuals with CAD and EDS, as both are important to guide appropriate therapy in patients with CAD.

Improved follow-up by peripheral arterial tonometry in CPAP-treated patients with obstructive sleep apnea and persistent excessive daytime sleepiness.

OSA-patients with persistent excessive daytime sleepiness (EDS) despite CPAP treatment are challenging in daily clinical life. To rule out residual sleep-disordered breathing (SDB), CPAP device-derived data are used in outpatient setting. In case of no pathological finding, a more intensive work-up with is necessary. 6-channel portable monitoring (6Ch-PM) is frequently used to exclude residual SDB. Peripheral arterial tonometry (PAT), as embodied in the WatchPAT device, represents an alternative technique for detecting SDB based on changes in autonomic tone. We wanted to investigate whether PAT might be a useful tool to improve diagnostic work-up in this specific patient group by better identifying residual SDB due to insufficient CPAP-adjustment. Forty-nine OSA patients (39 male, 10 female) with sufficient CPAP treatment according to device-derived data were consecutively recruited. EDS was assessed by Epworth Sleepiness Scale (ESS). All patients underwent home-based CPAP therapy control by 6Ch-PM and portable monitoring using PAT technology on two consecutive nights. A sequence of both types of monitoring was randomized to prevent possible first night effect bias. Twelve out of 49 patients showed persistent EDS according to ESS (ESS > 10 points). 6Ch-PM showed a residually increased AHI under CPAP-treatment in 2 of those 12 subjects (positive predictive value, PPV = 16.7%). PAT-PM revealed 5 patients of those 12 with residual SDB (PPV = 41.7%). PAT could detect significantly more residual SDB under CPAP treatment than 6Ch-PM. Diagnostic work-up of CPAP-treated OSA patients with persistent EDS might be optimized, as insufficient pressure level adjustments could be recognized more precisely in time, possibly preventing more resource-consuming procedures, and potentially increased morbidity. DRKS00007705.

Course, risk factors, and mental health outcomes of excessive daytime sleepiness in rural Chinese adolescents: A one-year prospective study

BackgroundThis study aimed to examine the one-year incidence and persistence of excessive daytime sleepiness (EDS) in rural Chinese adolescents and their risk factors. In addition, we also aimed to explore the potential bidirectional associations of EDS with anxiety symptoms and depressive symptoms. MethodsA total of 3736 adolescents from 5 high schools from rural area in the south China were eligible for follow-up. Among them, 2787 responded to follow-up after one year. EDS was defined as having a total score of the Epworth Sleepiness Scale over 10. ResultsThe one-year persistence rate and incidence rate of EDS were 27.6% and 9.3%, respectively. After controlling for age and sex, new incident EDS was significantly associated with perceived high study stress, depressive symptoms, insomnia symptoms, and high life events at baseline. Baseline EDS predicted new onsets of depression and anxiety at follow-up. Cross-lagged analyses further revealed that there were bidirectional associations between EDS and anxiety symptom and between EDS and depressive symptoms. Persistent EDS was only associated with eveningness chronotype. In particular, short sleep duration and obesity were associated with neither new incidence nor persistence of EDS in this population. LimitationsAll measures relied on self-reported questionnaires rather than objective assessments, which might have led to report bias. ConclusionsWe have identified a number of risk factors of the one-year incidence of EDS (such as perceived high study stress, depressive symptoms, insomnia symptoms, and high life events) and persistence of EDS (eveningness chronotype) in rural adolescents. There is a reciprocal relationship of EDS with anxiety and depression. In this population, sleep loss and obesity seem not related to the course of EDS.

Incidence, worsening and risk factors of daytime sleepiness in a population-based 5-year longitudinal study

Excessive daytime sleepiness (EDS) is highly prevalent in the general population; however little is known about its evolution and predictors. Our objectives were to document its natural history, provide estimates of its prevalence, incidence and persistence rates, and to identify predictors of increased daytime sleepiness (DS) in a longitudinal community study of 2157 adults over 5 years. Participants completed postal assessment at baseline and at each yearly follow-up. DS was evaluated by the Epworth Sleepiness scale (ESS). At baseline, 33% reported EDS (ESS > 10) with 33% of them reported persistent EDS. Of those without EDS at baseline, 28% developed incident EDS (15% were persistent) and 31% increased DS (augmentation ≥4-points between two consecutive evaluations). Younger age and depression were independent predictors of incident EDS and DS increase while lower coffee consumption, smoking, insomnia, tiredness and chronic pain were associated with incident EDS, and living alone with DS increase only. Persistent vs transient EDS or DS showed association with poor general health including metabolic diseases. Thus, sleepiness fluctuated over time and it was predicted by common lifestyle and psychological factors potentially modifiable. However, persistent sleepiness was associated with chronic medical diseases thus highlighting a homogeneous group at risk requiring a dedicated management.

Obesity, Hypersomnolence, and Quality of Sleep: the Impact of Bariatric Surgery.

Obesity is commonly associated with poor sleep, excessive daytime sleepiness (EDS) and depressive mood but the impact of bariatric surgery on these conditions is incompletely understood. This study aimed to investigate the course of EDS and sleep quality in bariatric surgery patients in relation with changes in body weight and depressive symptoms. In patients consecutively submitted to bariatric surgery, baseline and postoperative sleep quality were evaluated by the Pittsburgh Sleep Quality Index (PSQI), excessive daytime sleepiness by the Epworth Sleepiness Scale (ESS), risk for OSA by the Berlin Questionnaire (BQ), and depressive symptoms by the Beck Depression Inventory-Short Form (BDI). Comorbidities were assessed by interview and chart review. Sixty patients (M/F=9/51) with a mean (±SD) age of 34.7±9.2years and body mass index (BMI) of 46.04±7.52kg/m2 were studied. Bariatric surgery improved PSQI score (6.4±3.8 versus 4.1±2.8; p<0.001), ESS score (8.1±4.7 versus 6.0±3.3; p<0.001), BDI score (9.8±7.0 versus 4.7±4.6; p=0.001), and risk for OSA (68.3 versus 5%). Twelve of the 18 subjects with baseline EDS (ESS≥10) developed normal ESS score after surgery. In these subjects, significant postoperative improvement in depressive symptoms score was observed (12.0±9.0 versus 5.5±5.0; p=0.041), in contrast to the remaining six cases with persistent EDS, who showed no significant change in these symptoms (5.5±5.0 versus 3.2±3.1; p=0.416). Bariatric surgery has a beneficial effect on sleep quality and EDS. Postoperative improvement in EDS can be related to a reduction in depressive symptoms.

Depressive Symptoms Before and After Long-term CPAP Therapy in Patients With Sleep Apnea

The outcome of depressive symptoms under CPAP therapy for OSA-hypopnea syndrome (OSAHS) has been poorly evaluated. In this multicenter, prospective cohort study, we evaluated the prevalence and correlates of persistent depressive symptoms after long-term CPAP therapy for OSAHS. This study included 300 patients with OSAHS and depressive symptoms (13-item, self-rated Pichot depression scale [QD2A] ≥ 7) at diagnosis. The primary dependent variable was persistent depressive symptoms after ≥ 1 year of CPAP therapy. Multivariate regression analyses were performed to determine variables independently associated with the persistence of depressive symptoms. After an average of 529 days (range, 365-1,569 days) of CPAP therapy, the mean (SD) QD2A score decreased from 9.2 (2.0) to 5.4 (4.0) (P &lt; .0001), but 125 patients (41.7%) presented persistent depressive symptoms. The persistence of depressive symptoms was independently associated with persistent excessive daytime sleepiness (EDS) (OR, 2.72; 95% CI, 1.33-5.61), comorbid cardiovascular disease (OR, 1.76; 95% CI, 1.02-3.00), and female sex (OR, 1.53; 95% CI, 1.09-2.13). A positive linear trend was observed for the adjusted OR of persistent depressive symptoms with decreasing CPAP effect on the Epworth sleepiness scale (P &lt; .0001). CPAP therapy does not resolve depressive symptoms in many patients with OSAHS. Persistent depressive symptoms are strongly associated with EDS. Active monitoring of depressive symptoms is needed in patients with OSAHS who are treated with CPAP. Interventional trials are required to evaluate the impact of antidepressants, cognitive behavioral therapy, or both on comorbid depression in patients with OSAHS.

Incidence and remission of sleep related symptoms in children and associations with health-related quality of life; A 7-year follow-up of the TuCASA cohort

Introduction Sleep disturbances are common in adolescents; some studies have shown that this may adversely affect their quality of life. However, there is little evidence on incidence and remission of sleep problems from childhood to adolescence and the association with health-related quality of life (QoL). Materials and methods Sleep Screening questionnaires were collected on Hispanic and Caucasian children 6–12 years of age at baseline, and again 7 years after during follow-up, when participants were 12–20 years. Excessive daytime sleepiness (EDS) and difficulty initiating and maintaining sleep (DIMS) were present if they occurred frequently or more. Health-related QoL was assessed at follow-up using the Pediatric Quality of Life Inventory and three summary scores, ranging from 1 to 100, were evaluated: psychosocial health (PS), physical function (PF), and total scale scores (TS). Prevalence, incidence, and remission of sleep symptoms were computed and analyzed for association with health-related QoL. Results The mean ages at baseline and follow-up were 8.8 and 15.4 years. There were 50.2% males and 30.6% Hispanics. Incidence rates of EDS and DIMS were 39.1% and 58.9%, and remission rates were 53.1% and 36.2%, respectively. Separate linear regressions models predicting health-related QoL showed that participants with persistent EDS had lower mean values for TS (coeff. = −9.2, p = .006), PS (coeff. = −8.8, p = .025), and PF (coeff. = −10, p = .002) as compared with participants who never had EDS or those with remittent EDS combined. Participants with persistent DIMS had lower mean values for TS (coeff. = −6.8, p = .001) and PS (coeff. = −8.4, p = .001) as compared with participants who never had DIMS or those with remittent DIMS combined. When participants with persistent DIMS were compared with those with remittent DIMS only, the associations between DIMS and health-related QoL, became non-significant. However, the association between EDS and health-related QoL remained (coeff. = −13.3, p = .02). Conclusion Substantial variability of self-reports of sleep problems exists as children age from childhood to adolescence. Nevertheless, there are a small number of young children who persistently have sleep problems over this age span and these problems are associated with lower health-related quality of life. These associations appear to be driven primarily by EDS. Acknowledgements The TuCASA study was supported by NHLBI grant HL 62373 . Silva, G.E. was supported by NHLBI grant HL 62373-05A2S1 .

Sleep Disorders in Parkinson Disease

Sleep is affected in a large number of patients with Parkinson disease. The mechanisms by which this occurs and the different types of sleep disorders that a patient with Parkinson disease may suffer (insufficient or fragmented sleep, persistent excessive daytime sleepiness, sudden onset of sleep episodes, obstructive sleep apnea (OSA), rapid eye movement sleep behavior disorder, and restless legs syndrome) will be reviewed in this study, as well as their relationship with the dopaminergic system. Finally, the most effective treatments will be proposed.

Daytime Sleepiness and EEG Spectral Analysis in Apneic Patients Before and After Treatment With Continuous Positive Airway Pressure

Obstructive sleep apnea syndrome (OSAS) is characterized by recurrent apneas during sleep, resulting in repetitive hypoxemic episodes and interruptions of the normal sleep pattern. A previous study showed EEG slowing (ie, a higher ratio of delta + theta frequencies to alpha + beta frequencies on EEG) during rapid eye movement (REM) sleep and wakefulness in untreated OSAS patients. STUDY AND OBJECTIVES: To determine whether EEG slowing is reversible with continuous positive air pressure (CPAP) treatment and to verify whether the persistence of excessive daytime sleepiness (EDS) is correlated with residual slowing of the EEG. Ten healthy subjects (9 men and 1 woman) and 14 patients with moderate-to-severe OSAS (13 men and 1 woman) were studied before and after 6 months of treatment with CPAP. Untreated OSAS patients showed EEG slowing in frontal and central cortical regions during both wakefulness and during REM sleep compared to healthy control subjects. This EEG slowing was found to be independent of time spent with arterial oxygen saturation < 90%, severity of OSAS, or mean sleep latency as determined by the multiple sleep latency test. CPAP treatment was found to correct the EEG slowing for both REM sleep and wakefulness. Daytime sleepiness also greatly improved with treatment, but some degree of somnolence remained. CPAP treatment was found to correct the EEG slowing that was observed in untreated OSAS patients. Persistent EDS may be related to persistent obesity after CPAP treatment.