Belinda Miller

Neurobehavioral performance impairment in insomnia: relationships with self-reported sleep and daytime functioning

STUDY OBJECTIVES Despite the high prevalence of insomnia, daytime consequences of the disorder are poorly characterized. This study aimed to identify neurobehavioral impairments associated with insomnia, and to investigate relationships between these impairments and subjective ratings of sleep and daytime dysfunction. DESIGN Cross-sectional, multicenter study. SETTING Three sleep laboratories in the USA and Australia. PATIENTS Seventy-six individuals who met the Research Diagnostic Criteria (RDC) for Primary Insomnia, Psychophysiological Insomnia, Paradoxical Insomnia, and/or Idiopathic Childhood Insomnia (44F, 35.8 ± 12.0 years [mean ± SD]) and 20 healthy controls (14F, 34.8 ± 12.1 years). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Participants completed a 7-day sleep-wake diary, questionnaires assessing daytime dysfunction, and a neurobehavioral test battery every 60-180 minutes during an afternoon/evening sleep laboratory visit. Included were tasks assessing sustained and switching attention, working memory, subjective sleepiness, and effort. Switching attention and working memory were significantly worse in insomnia patients than controls, while no differences were found for simple or complex sustained attention tasks. Poorer sustained attention in the control, but not the insomnia group, was significantly associated with increased subjective sleepiness. In insomnia patients, poorer sustained attention performance was associated with reduced health-related quality of life and increased insomnia severity. CONCLUSIONS We found that insomnia patients exhibit deficits in higher level neurobehavioral functioning, but not in basic attention. The findings indicate that neurobehavioral deficits in insomnia are due to neurobiological alterations, rather than sleepiness resulting from chronic sleep deficiency.

Prevalence of depression in patients referred with snoring and obstructive sleep apnoea.

Depression and obstructive sleep apnoea are two common entities, with common symptoms that make identification of either condition difficult. Our aim was to examine, within a group of patients referred with snoring and obstructive sleep apnoea, (i) the prevalence of depression with the 14‐question Hospital Anxiety and Depression Scale (HADS), (ii) the correlation between the two lead depression symptoms from the Mini‐International Neuropsychiatric Interview (MINI) and HADS, and (iii) the relationship between depression symptoms with physiological markers of OSA.

Negotiating hope with chronic obstructive pulmonary disease patients: a qualitative study of patients and healthcare professionals

Background:  The information needs of patients with chronic obstructive pulmonary disease (COPD) towards the end of life are poorly understood.

The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial

Background Positive expiratory pressure (PEP) is a technique used to enhance sputum clearance during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The impact of PEP therapy during acute exacerbations on clinically important outcomes is not clear. This study sought to determine the effect of PEP therapy on symptoms, quality of life and future exacerbations in patients with AECOPD. Methods 90 inpatients (58 men; mean age 68.6 years, FEV1 40.8% predicted) with AECOPD and sputum expectoration were randomised to receive usual care (including physical exercise)±PEP therapy. The Breathlessness, Cough and Sputum Scale (BCSS), St Georges Respiratory Questionnaire (SGRQ) and BODE index (Body mass index, airflow Obstruction, Dyspnoea, Exercise tolerance) were measured at discharge, 8 weeks and 6 months following discharge, and analysed via linear mixed models. Exacerbations and hospitalisations were recorded using home diaries. Results There were no significant between-group differences over time for BCSS score [mean (SE) at discharge 5.2 (0.4) vs 5.0 (0.4) for PEP and control group, respectively; p=0.978] or SGRQ total score [41.6 (2.6) vs 40.8 (2.8) at 8 weeks, p=0.872]. Dyspnoea improved more rapidly in the PEP group over the first 8 weeks (p=0.006), however these benefits were not observed at 6 months. Exacerbations (p=0.986) and hospitalisations (p=0.359) did not differ between groups. Conclusions We found no evidence that PEP therapy during AECOPD improves important short-term or long-term outcomes. There does not appear to be a routine role for PEP therapy in the management of such individuals.

Advance care planning education in pulmonary rehabilitation: A qualitative study exploring participant perspectives

Background: Advance care planning is considered to have an important role in the management of people with chronic lung disease; however, uptake in clinical practice remains limited. Participant acceptance of the inclusion of an advance care planning information session in pulmonary rehabilitation and maintenance programmes could support a practical solution. Aim: To evaluate the introduction of a structured group advance care planning information session from the perspective of participants in pulmonary rehabilitation and maintenance programmes. Design: Prospective qualitative study with semi-structured interview transcripts analysed using iterative thematic analysis. Setting/participants: Participants in pulmonary rehabilitation and maintenance programmes at a tertiary metropolitan hospital and two affiliated community sites. Results: Sixty-seven participants with a range of chronic lung diseases were interviewed with ages ranging from 39 to 88 years, forced expiratory volume in 1 s (FEV1) ranging from 18% to 130% predicted and 6-min walk distance ranging from 105 to 619 m. Sixteen participants (24%) had previously heard of advance care planning. Major themes were that participants valued the advance care planning information and thought pulmonary rehabilitation was an appropriate setting. The group education format was well accepted and perceived to have advantages over individual sessions. Participants were happy to receive the information from a non-medical facilitator. Non-attendees had usually missed the session for reasons unrelated to content. A small number of participants felt advance care planning was not appropriate for them, but all recognised its value for other participants. Conclusions: Participants in our pulmonary rehabilitation and maintenance programmes value the opportunity to participate in a structured, group-based advance care planning session. Consideration should be given to broader inclusion of advance care planning education into existing pulmonary rehabilitation and maintenance programmes for people with chronic respiratory disease.

Palliative care for patients with chronic obstructive pulmonary disease: exploring the landscape

Patients with chronic obstructive pulmonary disease experience a substantial symptom burden, high levels of psychosocial need and significant mortality. This epidemiological study reveals that the majority of patients are cared for in the public hospital system (64%) and generally die in hospital (72%) with a number of identifiable predictors of 6‐month mortality. Our results suggest that palliative care services need to be redirected from a community‐based admission focus to a model that is responsive to emergency and acute care hospital systems.

Circadian Phase and Phase Angle Disorders in Primary Insomnia

Objectives We aimed to identify the prevalence of circadian phase and phase angle abnormalities in patients with insomnia. Methods We conducted a cross-sectional, multicenter study at three sleep laboratories in the United States and Australia. Patients with insomnia and healthy control participants completed a sleep log for 7 days. Circadian phase was assessed from salivary dim light melatonin onset (DLMO) time during a 12-hour laboratory visit. Results Seventy-nine patients meeting the Research Diagnostic Criteria for Primary, Psychophysiological, Paradoxical, and/or Idiopathic Childhood Insomnia (46 females, 35.5 ± 12.3 years [M ± SD]) and 21 controls (14 females, 34.4 ± 11.8 years). As compared to controls, patients with insomnia tried to initiate sleep on average at the same clock time (24:17 ± 1:17 hours vs. 24:13 ± 1:30 hours, respectively; p = .84) but had a later average DLMO times (20:56 ± 1:55 hours, 18:17-01:21 vs. 22:02 ± 2:02 hours, 17:11-04:52, respectively; p = .04). Consequently, patients with insomnia slept at an earlier circadian phase than controls (phase angle, bedtime-DLMO 2:13 hours (± 1:43) vs. 3:10 hours (± 1:08), respectively; p = .008), of whom 10% tried to sleep at or before DLMO (compared to 0 controls), and 22% tried to sleep before or within 1 hour after DLMO (compared to 6% of controls). Conclusions A substantial proportion (10%-22%) of patients with insomnia initiate sleep at too early a circadian phase, implicating a circadian etiology for their insomnia. Outpatient circadian phase assessments should be considered to improve differential diagnoses in insomnia and to inform the development of appropriately timed circadian-based treatments.

Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease: a questionnaire survey

OBJECTIVES To identify urinary incontinence and its impact on men with stable chronic obstructive pulmonary disease (COPD) and men without lung disease. DESIGN Prospective questionnaire study. SETTING Outpatients attending a public metropolitan hospital. PARTICIPANTS Men with COPD (n=49) and age-matched men without lung disease (n=36). INTERVENTIONS Validated questionnaires to identify the prevalence and impact of urinary incontinence. MAIN OUTCOME MEASURES Prevalence of urinary incontinence and relationship with disease-specific factors, and relationship of urinary incontinence with anxiety and depression. RESULTS The prevalence of urinary incontinence was higher in men with COPD (n=19/49) compared with men without lung disease (n=6/36; P=0.027). In men with COPD, symptoms of urgency were more prevalent in men with urinary incontinence (P=0.005), but this was not evident in men without lung disease (P=0.101). Only men with COPD reported symptoms of urgency associated with dyspnoea, and this did not vary between men with and without urinary incontinence (P=0.138). In men with COPD, forced expiratory volume in 1 second (FEV1) was lower in those with urinary incontinence compared with those without urinary incontinence {mean 38 [standard deviation (SD) 14] % predicted vs 61 (SD 24) % predicted; P=0.002}. The impact of urinary incontinence did not differ between the two groups (P=0.333). CONCLUSIONS Incontinence is more prevalent in men with COPD than in men without lung disease. The prevalence of urinary incontinence increases with greater disease severity, as reflected by lower FEV1. Screening for urinary incontinence should be considered in men with COPD and compromised lung function.

Factors that influence dietary intake in adults with stable chronic obstructive pulmonary disease

Aim Malnutrition is common amongst people with chronic obstructive pulmonary disease (COPD) and nutrition status is an important determinant of symptoms, morbidity and prognosis. Inadequate diet is recognised as a contributor to malnutrition in this population; however, there are limited studies exploring individual perspectives on nutrition amongst people with COPD. The aim of this study was to identify factors that influence dietary intake patterns in a metropolitan, stable COPD population. Methods This qualitative study investigated participants with stable COPD who attend pulmonary rehabilitation programs. Thirty participants underwent body composition measurements, completed a validated food frequency questionnaire and participated in a semi-structured interview to explore influences on food choices. Qualitative responses were examined using thematic analysis to identify major barriers and enablers shaping nutrition-related behaviours. Results Mean (±SD) body mass index was 26.6 ± 7.6 kg/m2. Analysis of food intake showed inadequate servings per day of dairy, fruit and vegetables. Common themes influencing food choices included: breathlessness and fatigue affecting appetite, swallowing problems, limited social and financial supports, reduced motivation and limited knowledge about the impact of nutrition on COPD. Conclusions Nutrition assessment of patients with COPD should encompass physical and social circumstances influencing dietary intake and support networks that promote healthy eating behaviours. Nutrition intervention should be tailored to individual circumstances, with ongoing follow-up to maintain motivation and adapt to changing clinical status.

Domiciliary non-invasive ventilation post lung transplantation

The benefits of domiciliary non‐invasive ventilation (NIV) post lung transplantation (LTx) have not previously been described. This was a single‐centre retrospective audit of patients requiring domiciliary NIV post‐LTx. Our aim was to describe indications for NIV and outcomes in chronic lung allograft dysfunction (CLAD) and diaphragmatic palsy.