Barry Krakow

Sleep disturbances and suicidal ideation in sleep medical center patients.

OBJECTIVEnThe purpose of this investigation was two-fold: first, we examined associations between suicidal ideation, maladaptive sleep patterns and abnormal sleep behaviors in a sleep center population, an understudied population in the domain of suicide research; and then, we explored whether significant associations remained after accounting for the possible influence of depressive symptoms.nnnMETHODnData were analyzed from intake information obtained from 1584 adult patients presenting at a community-based private sleep medical center. The sample was parsed into a Suicidal Ideation (SI) group (N=211) and No Suicidal Ideation (NSI) group (N=1373). Comparisons of these groups were made on measures of self-reported sleep complaints, habits, and behaviors, suicidal ideation, depressive symptoms, and associated psychopathology.nnnRESULTSnApproximately 13% of participants reported suicidal ideation. Clinically significant suicidal ideation was present in 4.5% of the sample. Compared to the NSI group, the SI group showed a pervasive pattern of significantly greater frequency or severity of sleep problems in areas of insomnia, nightmares and other parasomnia behaviors, poor sleep quality, and sleep-related psychophysiologic conditioning as well as worse sleep-related impairment and quality of life. Several relationships were significant after controlling for depressive symptoms.nnnDISCUSSIONnSuicidal ideation was consistently associated with a broad array of sleep complaints, even when controlling for level of depressive symptoms. As these self-reported sleep disturbances are treatable sleep disorders, future research should examine the efficacy of sleep and behavioral medicine for reducing the risk of suicidal ideation.

Nocturia and snoring: predictive symptoms for obstructive sleep apnea

PurposeCurrent screening for obstructive sleep apnea (OSA) emphasizes self-reported snoring and other breathing symptoms. Nocturia, a symptom with a precise pathophysiological link to sleep apnea, has not been assessed as a screening tool for this common disorder of sleep respiration. In a large sample of adults presenting to area sleep centers, we aimed to determine the predictive power of nocturia for OSA and compare findings with other markers of OSA commonly used to screen for this disease.MethodsThis was a retrospective chart review. A consecutive sample of 1,007 adult patients seeking treatment at two sleep centers in New Mexico completed detailed medical and sleep history questionnaires and completed diagnostic polysomnography testing. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of nocturia, snoring, high body mass index, sex, and age for OSA were determined. Hierarchical linear regression determined unique variance contribution to the apnea–hypopnea index, the objective measure of sleep apnea severity.ResultsThe results are as follows: sensitivities—snoring, 82.6% and nocturia, 84.8%; specificities—snoring, 43.0% and nocturia, 22.4%; PPVs—snoring, 84.7% and nocturia, 80.6%; and NPVs—snoring, 39.6% and nocturia, 27.9%. With hierarchical linear regression, patient-reported nocturia frequency predicted apnea–hypopnea index (OSA severity) above and beyond body mass index, sex, age, and self-reported snoring (Pu2009<u20090.0001).ConclusionsNocturia appears comparable to snoring as a screening tool for OSA in patients presenting to a sleep medical center. Research in urology and primary care clinics is needed to definitively clarify the use of nocturia as a screening instrument for obstructive sleep apnea.

Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity research

Posttraumatic stress disorder (PTSD) and sleep-disordered breathing (SDB) are common disorders, but limited data address their co-morbidity. Emerging research indicates PTSD and SDB may co-occur more frequently than expected and may impact clinical outcomes. This review describes historical developments that first raised suspicions for a co-morbid relationship between PTSD and SDB, including barriers to the recognition and diagnosis of this co-morbidity. Objective diagnostic data from polysomnography studies in PTSD patients reveal widely varying prevalence rates for co-morbidity (0-90%). Use of standard, recommended technology (nasal cannula pressure transducer) versus older, less reliable technology (thermistor/thermocouple) appears to have influenced objective data acquisition and therefore SDB rates in sleep studies on PTSD patients. Studies using higher quality respiratory sensors demonstrated the highest prevalence of SDB in PTSD patients. Clinical relevance, theoretical models and research recommendations are discussed. The lack of widely acknowledged, tested, or proven explanatory models and pathophysiological mechanisms to understand the relationship between these two disorders may prove formidable barriers to further investigations on prevalence and clinical relevance, albeit both conditions are associated with waking or sleeping hyperarousal activity, which may inform future studies.

Prevalence of sleep breathing complaints reported by treatment-seeking chronic insomnia disorder patients on presentation to a sleep medical center: a preliminary report

PurposeFew studies have examined the co-morbidity between insomnia and sleep-disordered breathing in the clinical setting. This study evaluated treatment-seeking insomnia patients and their self-report of sleep breathing complaints.MethodsA retrospective chart review was conducted on 1,035 consecutive treatment-seeking, chronic insomnia patients who reported insomnia as their primary problem upon seeking care at a private, community-based sleep medical center. Measurements included the insomnia severity index, standard subjective sleep measures as well as rankings, attributions, and self-reports about sleep breathing disorders, problems, and symptoms.ResultsA total of 1,035 adult, treatment-seeking insomnia patients indicated insomnia interfered with daytime functioning, and their average insomnia severity was in the range of a clinically relevant problem: total sleep time (5.50xa0h, SDu2009=u20091.60), sleep efficiency (71.05xa0%, SDu2009=u200918.26), wake time after sleep onset (120.70xa0min, SDu2009=u200992.56), and an insomnia severity index (18.81, SDu2009=u20095.09). Of these 1,035 insomnia patients, 42xa0% also ranked a sleep breathing disorder among their list of reasons for seeking treatment, another 13xa0% revealed a concern about a sleep breathing problem, and another 26xa0% reported awareness of sleep breathing symptoms. Only 19xa0% of this clinical insomnia sample reported no awareness or concerns about sleep breathing disorders, problems, or symptoms. A greater proportion of men than women reported significantly more sleep breathing disorders, problems, or symptoms.ConclusionsSleep breathing complaints were extremely common among a large sample of treatment-seeking, self-identified, adult chronic insomnia patients. Prospective prevalence research is needed to corroborate or revise these findings, and polysomnography should be considered in appropriate cohorts to determine the clinical relevance of treatment-seeking chronic insomnia patients sleep breathing complaints.

A two-year prospective study on the frequency and co-occurrence of insomnia and sleep-disordered breathing symptoms in a primary care population

OBJECTIVEnWe aimed to evaluate frequency and co-occurrence of insomnia and sleep-disordered breathing (SDB) symptoms and potential co-morbidity (complex insomnia).nnnMETHODSnA prospective self-assessment was conducted for adult patients with no prior sleep issues who presented to community-based primary care clinics for nonsleep-related complaints between November 2009 and June 2012.nnnRESULTSnA brief sleep health survey (SHS) assessed insomnia and SDB symptoms. Of 801 patients, 660 (82.4%) reported at least one insomnia symptom, and 289 (36.1%) reported an insomnia disorder (Insomnia Severity Index [ISI] >7 and self-reported daytime impairment due to insomnia). At least one SDB symptom was reported by 478 (59.7%) patients, and 177 (22.1%) reported two or more symptoms. Co-occurrence of insomnia and SDB symptoms (minimum of one symptom each of insomnia and SDB) occurred in 50.8% of the sample. Using liberal criteria to assess potential co-morbid disorders (complex insomnia), 187 (23.4%) patients reported an insomnia disorder and at least one SDB symptom. With more stringent criteria, including only those patients with moderate or severe insomnia disorders plus two SDB symptoms, 48 patients (6.0% of the sample or 16.6% of all patients with insomnia disorders) indicated potential complex insomnia.nnnCONCLUSIONSnCo-occurrence of insomnia and SDB symptoms as well as the rate of potential complex insomnia was common among a moderately large sample of primary care patients without prior evaluations or diagnoses of sleep disorders. Clinical and research implications are discussed.

Pharmacotherapeutic Failure in a Large Cohort of Patients With Insomnia Presenting to a Sleep Medicine Center and Laboratory: Subjective Pretest Predictions and Objective Diagnoses

OBJECTIVEnTo measure the frequency of pharmacotherapeutic failure and its association with the diagnosis of sleep-disordered breathing among patients with chronic insomnia disorder.nnnPATIENTS AND METHODSnIn a retrospective review of medical records from January 1, 2005, through December 31, 2012, we identified an inclusive, consecutive series of 1210 patients with insomnia disorder, 899 (74.3%) of whom used sleep aids either occasionally (168 [18.7%]) or regularly (731 [81.3%]). Patients presented to a community-based sleep medicine center in Albuquerque, New Mexico, with typical referral patterns: 743 (61.4%) were referred by primary care physicians, 211 (17.4%) by specialists, 117 (9.7%) by mental health professionals, and 139 (11.5%) by self-referral. Pharmacotherapeutic failure was assessed from subjective insomnia reports and a validated insomnia severity scale. Polysomnography with pressure transducer (an advanced respiratory technology not previously used in a large cohort of patients with insomnia) measured sleep-disordered breathing. Objective data yielded accuracy rates for 3 pretest screening tools used to measure risk for sleep-disordered breathing.nnnRESULTSnOf the total sample of 1210 patients, all 899 (74.3%) who were taking over-the-counter or prescription sleep aids had pharmacotherapeutic failure. The 710 patients taking prescription drugs (79.0%) reported the most severe insomnia, the fewest sleep-associated breathing symptoms, and the most medical and psychiatric comorbidity. Of the 942 patients objectively tested (77.9%), 860 (91.3%) met standard criteria, on average, for a moderate to severe sleep-associated breathing disorder, yet pretest screening sensitivity for sleep-disordered breathing varied widely from 63.7% to 100%. Positive predictive values were high (about 90%) for all screens, but a tool commonly used in primary care misclassified 301 patients (32.0% false-negative results).nnnCONCLUSIONnPharmacotherapeutic failure and sleep-disordered breathing were extremely common among treatment-seeking patients with chronic insomnia disorder. Screening techniques designed from the field of sleep medicine predicted high rates for sleep-disordered breathing, whereas a survey common to primary care yielded many false-negative results. Although the relationship between insomnia and sleep-disordered breathing remains undefined, this research raises salient clinical questions about the management of insomnia in primary care before sleep center encounters.

Prevalence of potential nonallergic rhinitis at a community-based sleep medical center

PurposeNonallergic rhinitis (NAR) is a common condition involving symptomatic nasal congestion, stuffiness, or rhinorrhea, which overlap with symptoms of allergic rhinitis. Scant research has examined NAR and sleep. The aim of this study was to assess the frequency of potential NAR symptoms in a large sample of sleep center patients.MethodsA retrospective chart review was conducted on 2658 adult patients at our sleep center from 2008 to 2012; 1703 reported clinically relevant nasal congestion. For this subset, potential NAR status (NAR+ vs NAR−) was determined using a brief survey. NAR groups were further divided into three sub-groups based on presenting chief complaints: insomnia (INS), nonrestorative sleep (NRS), and sleep-disordered breathing (SDB). Patients objectively diagnosed with SDB were also analyzed by NAR status. Validated scales for sleepiness, insomnia, anxiety, and depression were compared among the groups.ResultsPotential NAR+ comprised 70xa0% (1194 of 1703) of patients with congestion and showed significantly higher congestion scores than NAR− status [11.97 (3.62) vs 10.47 (3.37); pxa0=xa0.001; gxa0=xa00.42; 95xa0% CI, 0.32–0.53]. The proportion of potential NAR+ cases for each presenting chief complaint was nearly identical (range 69.6 to 71.2xa0%). However, the comparison of effects between NAR+ and NAR− cases within each presenting group (INS, NRS, SDB) was more consistently significant on the scales for insomnia, sleepiness, anxiety, and depression only in the SDB category. The same four symptoms, measured in those objectively diagnosed with SDB, were also significantly worse in NAR+ compared to NAR− patients.ConclusionsRegardless of presenting chief complaint and ultimate diagnosis of sleep-disordered breathing, potential nonallergic rhinitis was common in patients at a sleep medical center at a rate possibly greater than twice that reported in the general population. Potential NAR+ was associated with worse sleep and distress symptoms. In both prevalence and treatment studies, research must further evaluate the potential impact of NAR on specific sleep disorders.

Adherence and Subthreshold Adherence in Sleep Apnea Subjects Receiving Positive Airway Pressure Therapy: A Retrospective Study Evaluating Differences in Adherence Versus Use

BACKGROUND: Research on subthreshold compliance with positive airway pressure (PAP) therapy in sleep apnea patients may inform clinical sleep medicine practice. We retrospectively assessed compliant and subthreshold compliant sleep apnea subjects to test whether regular but fewer hours of PAP use would demonstrate clinically meaningful improvements and correlate with outcomes. METHODS: A chart review was conducted of 113 consecutive sleep apnea subjects, naive to treatment, who completed a titration study and filled a PAP therapy prescription. Objective data categorized subjects into 3 groups: compliant, subthreshold compliant, and minimal use. Outcome measures assessed changes in insomnia, sleepiness, and nocturia on average 7 months from PAP initiation. Correlation coefficients analyzed dose-response relationships between hours of use and changes in outcomes. RESULTS: Among 113 PAP attempters, 104 (92%) were current users. Among 93 users with objective data, regular (consistent) PAP users included 59 compliant and 21 subthreshold compliant, and 13 subjects were minimal users. Compliant users averaging 6.6 ± 1.3 h/night and 42.0 ± 12.1 h/week showed the largest outcome improvements (all P < .05) with moderate to large effects for insomnia (d = 0.94), sleepiness (d = 0.58), and nocturia (d = 0.56). Subthreshold users averaging 4.1 ± 0.7 h/night but only 18.0 ± 5.6 h/week showed a large effect for insomnia (d = 0.76, P = .03) and nonsignificant, small effects for sleepiness (d = 0.38) and nocturia (d = 0.22). Correlation coefficients showed a trend for decrease in insomnia (P = .08; r = .20) and a significant decrease in nocturia (P = .034; r = 0.25), each in association with hours of PAP use. CONCLUSIONS: In a clinical sample, 86% of sleep apnea subjects regularly used PAP, but adherence was 63%. Regular users showed clinical treatment effects and potential dose-response relationships, suggesting that the term use offers advantages over the term adherence. Currently, subthreshold compliance may not merit insurance coverage in many countries, an issue affecting many sleep apnea patients.

Reversal of PAP Failure With the REPAP Protocol

BACKGROUND: Re-titrations, an atypical approach to reverse PAP failure, was investigated retrospectively. METHODS: Application of our re-titration of PAP (REPAP) protocol in subjects with previous PAP failure assessed original technology (masks, modes, and pressures) in 273 subjects, of which 70% reported co-occurring psychiatric conditions. The REPAP protocol emphasized changes in pressure modes and settings to address expiratory pressure intolerance and residual breathing events; mask changes were facilitated. Objective sleep and breathing metrics and subjective post-titration ratings were analyzed in subsequent PAP users and non-users. RESULTS: Following REPAP protocol (average follow-up = 2 y), 196 of 273 subjects with previous PAP failure were PAP users, and 77 were non-users. Previous PAP failure was attributed to technology factors, including pressure intolerance, mask discomfort, adaptation difficulties, and no benefits. At second opinion re-titration, mask changes resolved discomfort, mouth breathing, or leak (91.2% of sample); pressure mode changes resolved expiratory pressure intolerance (83.5%); and pressure setting changes decreased residual breathing events and improved air flow (96.7%), all of which were associated with renewed PAP use. PAP users showed objective sleep improvements on re-titrations and reported better sleep quality than non-users. Multiple logistic regressions showed 2 subjective, re-initiation predictors: (1) post-re-titration ratings of better sleep quality and (2) less anticipated difficulty in using PAP after initial or multiple re-titrations. User rates were significantly higher for subjects completing multiple (n = 158) versus one (n = 115) re-titration (80% vs 61%, P = .001). In multiple re-titration subjects, PAP users showed significance or a trend for lower apnea-hypopnea index (P = .02, g = 0.48) and respiratory disturbance index (P = .07, g = 0.36) compared with non-users. Available user downloads averaged >5 h/night. CONCLUSIONS: Technology-related problems due to mask discomfort/leak, pressure intolerance, and residual breathing events were associated with PAP failure in subjects seeking second opinions. Technological solutions (changes in masks, modes, and pressures) were addressed during REPAP protocol, after which 72% of subjects re-initiated PAP use. These technological interventions were associated with improved objective and subjective sleep variables and reversal of PAP failure.

Sleep-Disordered Breathing and Posttraumatic Stress Disorder

Sleep-disordered breathing (SDB) and posttraumatic stress disorder (PTSD) are relatively common in isolation within the adult population. Data reflecting causes, prevalence, and long-term physical and psychological consequences are substantial for either condition. Less known is the prevalence of comorbidity among the two. Moreover, there is a dearth of literature explaining the biopsychosocial interactions, which likely contribute to development, maintenance, and exacerbation of symptoms when the conditions co-occur. In this chapter we review the scant literature on the comorbidity of SDB and PTSD regarding prevalence, clinical implications, and recommendations related to improved diagnostic assessment and treatment strategies.