Clinical Sleep Medicine Research Articles

SLEEP-DISORDERED BREATHING AND LONG-HAUL COVID-19: A CASE REPORT

SLEEP-DISORDERED BREATHING AND LONG-HAUL COVID-19: A CASE REPORT

Commemorative Issue: 15 Years of the Sleep Medicine Clinics Part 2: Medication and Treatment Effect on Sleep Disorders

Commemorative Issue: 15 Years of the Sleep Medicine Clinics Part 2: Medication and Treatment Effect on Sleep Disorders

Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance.

Lloyd R, Morgenthaler TI, Donald R, etal. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673-2680.

Sleep insecurity as a health disparity.

Sleep insecurity as a health disparity.

Enhancement of a Machine Learning Algorithm to Alert Sleep Clinicians of Patients at Risk for Narcolepsy, Using Nocturnal Polysomnography in General Sleep Medicine Clinics

Enhancement of a Machine Learning Algorithm to Alert Sleep Clinicians of Patients at Risk for Narcolepsy, Using Nocturnal Polysomnography in General Sleep Medicine Clinics

Inpatient CPAP adherence may predict post-discharge adherence in hospitalized patients screened high risk for OSA.

Despite increased recognition of sleep disordered breathing in hospitalized patients, studies are lacking on the impact of inpatient adherence with positive airway pressure (PAP) therapy on post-discharge adherence. To assess the predictive value of inpatient adherence to PAP therapy on post-discharge compliance and adherence. We reviewed data on individuals as part of a registry of a hospital-based sleep medicine program between August 2019 and December 2020. Consecutive patients identified as high risk for sleep disordered breathing based on our 2-tier screening process and initiated on Auto-PAP (APAP) therapy were included. Their adherence and post-discharge course were recorded. Primary objectives were polysomnography (PSG) compliance, sleep medicine clinic follow-up compliance, and 30-day adherence to PAP therapy if indicated by PSG. In total, 900 individuals were screened during the study period. Of these, 281 were offered inpatient PAP therapy. Patients on bilevel PAP therapy (88 patients) were excluded due to lack of objective compliance recording. Final analysis was performed on 193 patients. Of the 193 patients placed on inpatient APAP, 140 (73%) were adherent to the therapy with average usage of 367min per day versus 140min per day in the non-adherent (p < 0.001). There was no significant difference in oxygen desaturation index between the adherent and non-adherent groups (32.4 ± 21.9 events per hour and 34.5 ± 21.9 events per hour consistent; p = 0.5). No demographic and anthropometric characteristics or comorbid conditions were noted. Those who were adherent to PAP therapy in-hospital 47/140 (34%) underwent ambulatory PSG post-discharge compared to 7/53 (13%) of those non-adherent in-hospital (p = 0.002). The adherent group also had significantly higher likelihood for post-discharge clinic follow-up (p = 0.01) and adherence to outpatient PAP therapy (p = 0.01). Hospitalized patients identified as high risk for sleep disordered breathing have high adherence to PAP therapy during hospitalization and inpatient adherence predicts outpatient follow-up (both PSG testing and sleep clinic) and home PAP adherence.

Protocolizing perioperative OSA screening and management: moving in the right direction.

Protocolizing perioperative OSA screening and management: moving in the right direction.

CPAP setup by mail: we're not there yet.

CPAP setup by mail: we're not there yet.

Isolated REM sleep behavior disorder in North American older adults in an integrated health care system.

Identifying individuals with isolated rapid eye movement sleep behavioral disorder (iRBD) is an important clinical research priority for future synucleinopathy trials. Nevertheless, little is known about the breadth of clinical settings where diagnoses of iRBD are initially made. We conducted a retrospective cohort study using the electronic medical record system at the University of Michigan to identify patients aged ≥ 60 years with new diagnoses of iRBD between 2015 and 2020. We focused specifically on patients receiving primary care at the University of Michigan so that we might use the university's electronic medical record system to capture the full scope of their multispecialty care interactions and diagnoses in this integrated health care system. We used International Classification of Diseases, Ninth Revision and Tenth Revision, diagnosis codes to identify the time of initial clinical diagnosis. We found that 62/105 (59.0%) diagnoses were made by a sleep specialist, 9 (8.6%) by neurologists, and 30 (29.5%) by generalists or primary care (29.5%) providers. In addition, 67/105 (63.8%) diagnoses were made in the context of having available polysomnography results, while the remainder was made on the basis of clinical symptoms alone. The prognostic implications of iRBD were documented in 40/105 (38.1%) encounter notes and were more likely to occur in sleep clinic settings (chi-square = 12.74; P < .001) than in other contexts. Initial iRBD diagnoses occur in varied clinical settings in an integrated health care system and are often made without a confirmatory polysomnogram. Documented prognostic counseling is seen most often in sleep medicine clinics. Synucleinopathy prevention trials may be best designed around a sleep clinic-focused recruitment approach. Havis I, Coates T, Wyant KJ, Spears CC, Garwood M, Kotagal V. Isolated REM sleep behavior disorder in North American older adults in an integrated health care system. J Clin Sleep Med. 2022;18(9):2173-2178.

Commemorative Issue: 15 Years of the Sleep Medicine Clinics - Part 1: Sleep and Sleep Disorders

Commemorative Issue: 15 Years of the Sleep Medicine Clinics - Part 1: Sleep and Sleep Disorders

Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study.

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.

0798 Detriggered - a case of tenosynovitis ameliorated by CPAP

Abstract Introduction The influence of sleep quality and pain is bidirectional (1). Sleep loss can induce hyperalgesia through upregulated inflammatory mediators such as IL-6 and TNF (2, 3). Obstructive sleep apnea (OSA) is characterized by obstructive respiratory events, hypoxemia, sleep fragmentation, and ultimately poor quality sleep. Here we present a case of how the treatment of OSA with continuous positive airway pressure (CPAP) mitigated hand inflammation and trigger finger symptoms. Report of Cases: A 60 year old male with prediabetes, hypertension, and BMI 30 presented to primary care with bilateral finger pain and stiffness. Hand orthopedics noted a tender left A1-pully 4th finger with 20 degree flexion contracture and a palpable right 3rd finger flexor tendon nodule causing definite triggering. He was diagnosed with trigger finger and initially treated with steroid injections and again 5 months later due to persistent symptoms. 10 months after the initial orthopedic visit, orthopedics planned for surgical intervention, but patient missed his surgery for unknown reasons. 7 months later, sleep medicine evaluated the patient for snoring and daytime fatigue. He underwent home sleep apnea testing which revealed a respiratory event index (REI) of 36.7 which necessitated CPAP therapy. Unfortunately, the patient was then lost to follow up in sleep medicine clinic. More than a year later, the patient showed to clinic and found to have 100% CPAP compliance with residual REI of 0.7. He enthusiastically noted improvement of daytime fatigue and trigger finger symptoms when using CPAP. When he would forget to use CPAP at night or during naps, he would wake up with returned finger pain and stiffness. Per patient, the symptoms would then resolve after re-initiation of CPAP. This consistent association of CPAP and finger symptom amelioration continued even 8 months later in most recent follow up. Conclusion To our knowledge, this is the first report of trigger finger symptoms improving with treatment of OSA. One hypothesis is that through improved sleep quality, there is a dampening of chondrocyte proliferation of the retinacular sheath and allowing unrestricted motion of the flexor tendon (4). More studies are needed to evaluate the musculoskeletal benefits of CPAP for OSA. Support (If Any) 1. Haack M. Scott Sutherlandj. Et al. Pain sensitivity and modulation in primary insomnia. Eur J Pain. 2012, 16: 522-533.2. Chhangani BS, Roehrs Ta et al. Pain sensitivity in sleepy pain-free normals. Sleep, 209, 32:1011-1017.3. Li, Joule Sarah Appleton. Association of Musculoskeletal Joint Pain with Obstructive Sleep Apena, Daytime Sleepiness, and Poor Sleep Quality in Men. Arthritis Care and Research Vol 69. No 5. May 2017.4. Makkouk Al Hasan et al. Trigger finger: etology, evaluation, and treatment. Curr Rev Musculoskeltal Med 2008. 1:92-96.

0767 Clinical implementation of a program to improve PAP acceptance and adherence for sleep disordered breathing among Veterans: Preliminary results

Abstract Introduction Positive airway pressure (PAP) is the gold standard in treating sleep disordered breathing (SDB); however, consistent use of this therapy has challenges such as comfort and equipment optimization. Despite various educational, technological, psychosocial and pharmacological strategies, the average adherence rate of 34% have changed very little over the past 20 years. A recent study of 3013 US veterans determined a baseline average PAP adherence rate of 50%. We developed and implemented a novel PAP readiness education program (PREP) for veterans newly diagnosed with SDB in a Veterans Administration sleep clinic to promote greater PAP acceptance and adherence. Methods Patients (N=63, Mean age 62.2±12.4 years) with newly diagnosed SDB were offered a 1-hour telehealth session prior to initiating PAP therapy that included psychoeducation about SDB and PAP treatment expectations, with troubleshooting techniques (i.e. scheduled practice, mindfulness). A 1-week follow-up call was conducted to communicate PAP data and address treatment barriers. PAP use reports were downloaded and analyzed at 1-7 days (first week), 1-30 days (first month), and 31-60 days (60-days) post-PAP initiation. PAP acceptance was defined as ≥1 day of use and adherence as ≥4 hours of use at each timepoint. Results Among 63 Veterans offered PREP, 66.6% (n=42) participated in PREP. Among participants, acceptance of PAP was as follows: 57.1% used ≥1 day in the first week, 64.3% used ≥1 day in the first month, and 45.2% used ≥1 day at 60-days post-PAP initiation. Percent of days with use ≥4 hours was 28.9% ±30.4 in the first week and 24.9% ±30.0 in the first month. PAP adherence at 60-days post-PAP initiation was 34.3% ±38.5 at 60-days. Conclusion Implementation of a 1-session plus 1-week follow-up call PAP readiness education program within a sleep medicine clinic was well received by patients and resulted in PAP acceptance by 2/3 of veterans in the first month post-PAP initiation. PAP adherence results may have reflected the impact of a nationwide PAP device recall that occurred during the study period. Further work is needed to test this intervention in a clinical population and to identify predictors of PAP acceptance and adherence in real-world clinical settings. Support (If Any) AASM Foundation #211-FP-19, VAGLAHS GRECC and CSHIIP

0375 Effectiveness of an intelligent sleep management system in the US military: Preliminary results

Abstract Introduction There are well-recognized barriers limiting access to evidence-based sleep interventions in the military. Given the large number of patients seeking treatment and the shortage of trained specialist providers, demand greatly exceeds available supply. As part of a larger implementation effort, the purpose of this study was to evaluate health provider ratings of the effectiveness and usability of a novel sleep telehealth assessment at a busy military treatment facility. Methods Health providers were recruited from the Internal Medicine and Sleep Medicine clinics at Walter Reed National Military Medical Center. Effectiveness was defined a priori based on the established Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation science framework. Providers from participating clinics completed a questionnaire that measured specific aspects of effectiveness: perceived satisfaction, usability, improvement, credibility, risks, benefits, acceptability and overall satisfaction with a sleep assessment report. Results Providers (n=16) were surveyed regarding perceived satisfaction, usability, improvement, credibility, risks, benefits, and acceptability of the sleep assessment report were rated favorably, with each domain being rated with a positive or very positive response by more than 75% of providers. All providers viewed the usability of the report favorably and all but one provider had a positive view on the report improving their documentation of sleep problems. Conclusion Health care providers at our hospital rated a novel sleep telehealth assessment as highly effective across established key domains of implementation science. Providers were highly satisfied with the content, usability, and credibility of the report, and felt this intervention would improve their documentation. Research is ongoing to further evaluate the implementation of the system. Support (If Any) This research was supported by an investigator-initiated research award from the Department of Defense (via the Medical Technology Enterprise Consortium) to the University of Maryland, Baltimore (PI: EMW).

0841 Case Report: Can LSD be Associated with Chronic Exploding Head Syndrome?

Abstract Introduction Exploding head syndrome is a rare phenomenon characterized by a loud imagined noise at sleep onset. Less commonly, it is associated with a simultaneous stab of pain in the forehead. It may result in recurring arousals and anxiety regarding the events. The underlying pathophysiology remains unknown. Report of Cases: A 27 year old male with no past medical history presented to the sleep medicine clinic with a 2-year history of sleep-onset pain between his eyes, like “a flash of lightning,” associated with moderate to severe pain. He experiences “brain zaps” or “a jolt of electricity between his eyes every night.” He would yell and jolt out of bed due to this sensation. These episodes occur approximately 60 to 90 minutes after sleep onset almost every night, jolting him from sleep and lasting approximately 1 minute. He also has difficulty seeing in the dark and also eye twitching. He experiences palpitations, diaphoresis, and a sense of fear often with these episodes. He denies any neurological deficits or muscle jerks. He is not on any daily medications. He does not regularly use any sleep aids but has tried melatonin 3 mg in the past. Evaluation by ophthalmology has ruled out ophthalmologic and neuro ophthalmic causes. He does report use of illicit substances including lysergic acid diethylamide (LSD), marijuana, methylenedioxymethamphetamine (MDMA), and cocaine. He did not experience any unpleasant effects after his first use of LSD, however within minutes of his second ingestion, he felt a sharp pain on his nasal bridge and forehead 10/10 in intensity. He states that since then, this pain has recurred almost every night. He does not have a family history of any neurologic disorders or migraines. The current plan for workup includes an in lab polysomnography with seizure montage and, if negative, a trial of a tricyclic antidepressant is planned. Conclusion This case illustrates the potential issues after LSD use causing severe dopaminergic and serotonin surge with drug use and the value of a complete history. Awareness of a possible correlation is clinically useful and may serve as a caution in the use of recreational drugs. Support (If Any)

0457 Development and utility of a mobile health application integrated with the electronic heath record for treatment of chronic insomnia disorder

Abstract Introduction Cognitive behavior therapy for insomnia (CBT-I), a first-line therapy for patients with chronic insomnia disorder (ChID), is underutilized due to reduced access to trained providers and other barriers. We developed an interactive care plan (ICP) combining individual aspects of CBT-I. This ICP, which integrates with the electronic health record (EHR), is designed to deliver personalized and scalable CBT-I to patients with ChID. We report data from initial implementation and evaluation of a ChID ICP deployed at a tertiary sleep medicine clinic. Methods The ICP was developed following patient and provider interviews and focus groups. Patients diagnosed with ChID were offered enrollment and engaged in the ICP through an app. The ICP has embedded logic that may escalate care or offer an exit from the program, depending upon the patient’s response to questions. Key variables ascertained from the patient included sleep efficiency (SE), sleep timing and the Insomnia Severity Index (ISI), and how satisfied they were with their progress (Likert scale). We also measured In Basket messaging related to use of the ICP. Results A total of 222 patients [57% female, age=56.4±15.9 years (average ±SD), 92.7% white] were enrolled in the initial 120 days of ICP implementation. Most referrals were initiated by physicians or advanced practitioners (77.9%). ISI at initiation was 15±5.18 and SE was 74.55±16.65%. Patients spent 35.9±26.25 days engaging with the ICP. The ISI score at 28 days was 12.89±4.98 and SE was 78.9±13.4% with both showing significant improvement from baseline (p=0.013; p=0.002; respectively). Self-rated satisfaction with progress did not significantly correlate with actual improvement in ISI or SE (p&amp;gt;0.05). The ICP generated 3.89±2.3 In Basket messages per patient. Conclusion Patients who actively engaged with the ICP showed significant improvements in insomnia severity and sleep efficiency. While a majority of the patients were neutral towards the ICP and only a small minority expressed dissatisfaction, these data indicate that the ICP will have clinical utility in busy sleep medicine practices with reduced access to behavioral sleep specialists. Support (If Any)

0489 Sleep Disordered Medicine: A Residents Perspective

0489 Sleep Disordered Medicine: A Residents Perspective

0850 Exploding Head syndrome and Hypersomnia

Abstract Introduction Exploding head syndrome (EHS) is a hypnagogic parasomnia where the patient experiences a loud noise or flash of light and often reports distress secondary to the stimulus. EHS is relatively uncommon, and to our knowledge, there has been only one published report of comorbid EHS and narcolepsy, describing a 38-year-old male. This report focuses on a pediatric case of EHS, evaluating possible comorbid narcolepsy and sleep apnea. Report of Cases: Eight-year-old male was referred for excessive daytime sleepiness. He endorsed trouble staying awake in school, both in the morning and after lunch time. His Epworth in clinic was a 16, despite nightly sleep duration ≥8 hours. He also endorsed weakness secondary to strong emotions and was observed to have difficulty grasping and holding a pencil while tickled. Patient and his caregiver denied snoring, witnessed apnea, dream enactment, and symptoms of restless leg syndrome. However, the patient did admit to auditory hallucinations, occurring about twice per week during the transition from wakefulness to sleep. He described the hallucination as a banging sound and the sound of clinging bracelets, noting he has searched for the source of the stimulus, but has never been able to find a cause. Patient’s mother denied hearing similar noises. No visual hallucinations or sleep paralysis noted. Polysomnography revealed 0 Central Sleep Apneas, 0 Mixed Apneas, 10 Obstructive Apneas, and 12 hypopneas. The mean duration of these events was 0 seconds. The patient’s Apnea-Hypopnea Index (AHI) was 2.5 and had a REM AHI of 8.3. Patient was supine 75% of the night. Conclusion This case illustrates a unique hypnagogic parasomnia in a pediatric patient. At this point, the patient’s symptoms would suggest EHS characterized by auditory hallucinations that involve hearing the banging sound, upon transition from sleep to wake. The patient also exhibits some narcolepsy type symptoms - hypersomnia, Epworth of 16, and subtle symptoms of cataplexy. In lab PSG – showed overall AHI of 2.5, REM AHI of 8.3- oxygen nadir 90%. Patient referred to ENT for tonsillectomy and adenoidectomy. With follow up NPSG and MSLT if still sleepy. He was referred to behavioral sleep medicine clinic to address anxiety secondary to EHS, but did not attend. Support (If Any)

0430 Beyond symptoms: Using the Cost of Insomnia Checklist to Characterize the Subjective Burden of Insomnia

Abstract Introduction Traditional symptom focused assessments do not characterize the subjective impact of insomnia on patient's function and quality of life (QOL). The authors developed the Cost of Insomnia Checklist (CIC) to evaluate the effects of insomnia in the life domains most meaningful to patients. In bringing attention and awareness to these areas, such a tool may increase patient motivation to look for, initiate, and or persist in treatment. It may also help overcome habituation effects that lead patients to minimize the seriousness of insomnia. Methods The CIC has 68 items across seven categories (financial; health; family; cognition; mental and emotional; work; social and recreational). We developed CIC items based on clinical interviews with chronic insomnia patients in a behavioral sleep medicine clinic. Ninety-five patients completed the CIC during their clinical evaluation for chronic insomnia. Results Participants were 53% female, 81% white, 57% employed, 56% married, and 23% living alone with a mean age of 50.48 (+/- 16.03) and mean BMI of 24.91 (+/-5.29). Patients endorsed an average of 21.9 (SD 33.9; Median=21) items with a range of 4 to 52 items. The most often endorsed items (&amp;gt;70%) focused on not feeling rested, worry about sleep, daytime sleepiness and fatigue, and memory and attention problems. 97% of respondents endorsed one or more additional items. The most frequently endorsed additional items were “can't maintain energy level” (69.5%), “too tired to exercise” (57.9%), “discomfort of sleeplessness” (56.8%), “irritable/unkind to others” (55.8%), “can't think of the words I want to use” (54.7%), “unmotivated/uninterested” (54.7%), “daytime discomfort after a bad night” (53.7%), “stressed without good reason” (52.6%), “worry about daytime function” (51.6%), “news/doctors tell me Insomnia is bad for me” (50.5%). Conclusion The CIC evaluates the effect of insomnia in many life domains and may help patients recognize the impact of insomnia on daytime function and QOL. Future studies will measure how the CIC correlates with treatment participation, adherence, and outcomes. Future studies will also support revision of the CIC to keep only items not measured by other instruments. Support (If Any) None

0863 A Unique case of sleep state misperception in an elderly patient

Abstract Introduction Insomnia is a widespread condition, especially in the elderly population. While the International Classification of Sleep Disorders (ICSD) third edition appropriately removed primary insomnia subtypes from the classification, our case illustrates the importance of these factors in considering a chronic insomnia disorder diagnosis. We present a case of severe subjective insomnia with no apparent objective findings, instead with evidence of excellent sleep efficiency on the contrary. Report of Cases: A 76-year-old male with a past medical history of anxiety and a recent diagnosis of early Parkinson's disease presented to the Sleep medicine clinic with two years of insomnia which started after his retirement. The patient felt difficulty with falling asleep every night. He underwent a sleep study and was found to have sleep-disordered breathing, which responded well to Bilevel positive airway pressure (BiPAP) therapy. However, insomnia symptoms persisted and were resistant to multiple medications, including Mirtazapine, Melatonin, and Suvorexant. He was referred for Cognitive Behavioral Therapy with minimal to no improvement in his symptoms. Conversely, a one-week Actigraphy recording on Bipap therapy surprisingly revealed an excellent sleep efficiency with near-continuous seven to eight hours of sleep every night. The etiology of chronic insomnia is poorly understood but is typically multifactorial, as described in the second edition of ICSD. In this case, paradoxical insomnia played a significant role in the patient's clinical presentation. Paradoxical insomnia is defined as thoughts or perceptions of time asleep as wakefulness, with objective measures documenting normative amounts of sleep. Previous work suggests that alterations in the sleep/arousal system may contribute to this apparent mismatch between conventional objective sleep measures and subjective reports. Conclusion This case demonstrates the challenge of effectively diagnosing and managing chronic insomnia. While the new classification guidelines from the ICSD appropriately remove insomnia subtypes from the diagnostic paradigm, familiarity with these previously described subtypes may aid clinical decisions. Crucial to this discussion is that previously described "secondary" or "subtypes" of primary insomnia may develop an independent clinical course that may require further attention. Support (If Any) ICSD 2nd,3rd editions.