Christopher J. Lettieri

Sleep Disturbances Among Soldiers With Combat-Related Traumatic Brain Injury

BACKGROUNDnSleep complaints are common among patients with traumatic brain injury. Evaluation of this population is confounded by polypharmacy and comorbid disease, with few studies addressing combat-related injuries. The aim of this study was to assess the prevalence of sleep disorders among soldiers who sustained combat-related traumatic brain injury.nnnMETHODSnThe study design was a retrospective review of soldiers returning from combat with mild to moderate traumatic brain injury. All underwent comprehensive sleep evaluations. We determined the prevalence of sleep complaints and disorders in this population and assessed demographics, mechanism of injury, medication use, comorbid psychiatric disease, and polysomnographic findings to identify variables that correlated with the development of specific sleep disorders.nnnRESULTSnOf 116 consecutive patients, 96.6% were men (mean age, 31.1 ± 9.8 years; mean BMI, 27.8 ± 4.1 kg/m²), and 29.5% and 70.5% sustained blunt and blast injuries, respectively. Nearly all (97.4%) reported sleep complaints. Hypersomnia and sleep fragmentation were reported in 85.2% and 54.3%, respectively. Obstructive sleep apnea syndrome (OSAS) was found in 34.5%, and 55.2% had insomnia. Patients with blast injuries developed more anxiety (50.6% vs 20.0%, P = .002) and insomnia (63% vs 40%, P = .02), whereas patients with blunt trauma had significantly more OSAS (54.3% vs 25.9%, P = .003). In multivariate analysis, blunt trauma was a significant predictor of OSAS (OR, 3.09; 95% CI, 1.02-9.38; P = .047).nnnCONCLUSIONSnSleep disruption is common following traumatic brain injury, and the majority of patients develop a chronic sleep disorder. It appears that sleep disturbances may be influenced by the mechanism of injury in those with combat-related traumatic brain injury, with blunt injury potentially predicting the development of OSAS.

Efficacy of an Adjustable Oral Appliance and Comparison With Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome

BACKGROUNDnWe sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, to our knowledge, and to provide a comparison with continuous positive airway pressure (CPAP).nnnMETHODSnWe conducted a retrospective analysis of patients using an aOA. Results of overnight polysomnography with aOA titration were evaluated and compared with CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model.nnnRESULTSnA total of 497 patients were given an aOA during the specified time period. The aOA reduced the mean apnea-hypopnea index (AHI) to 8.4 ± 11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI < 5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score by 2.71 (95% CI, 2.3-3.2; P < .001) at follow-up. CPAP improved the AHI by -3.43 (95% CI, 1.88-4.99; P < .001) when compared with an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (-5.88 [95% CI, -8.95 to -2.82; P < .001]). However, 70.1% of all patients achieved an AHI < 5 using CPAP compared with 51.6% for the aOA (P < .001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance.nnnCONCLUSIONSnIn comparison with past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, whereas CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.

Clinical and polysomnographic predictors of short-term continuous positive airway pressure compliance.

BACKGROUNDnPoor compliance and initial intolerance limit the effectiveness of continuous positive airway pressure (CPAP) in obstructive sleep apnea. Short-term compliance has been shown to predict long-term use. Unfortunately, few identified variables reliably predict initial CPAP tolerance and use. We sought to identify potential pretreatment variables that would predict short-term use of CPAP.nnnMETHODSnWe performed a retrospective review assessing short-term CPAP compliance after 4 to 6 weeks of treatment. Consecutive patients initiating CPAP therapy were included. Demographic and polysomnographic variables were correlated with objective measures of CPAP use. The average hours per night and percentage of nights of CPAP use were correlated with each variable. Variables were also associated with good vs poor compliance, which we defined as > 4 h per night > 70% of nights.nnnRESULTSnWe included 400 consecutive patients (78% male; mean age, 47 +/- 8 years). Of the measured variables, only age (48 +/- 8 years vs 46 +/- 7 years, p = 0.02) and use of a sedative/hypnotic during CPAP titration (77% vs 57.6%, p < 0.0005) were associated with better compliance. Those receiving a sedative/hypnotic had longer sleep times (345 +/- 42 min vs 314 +/- 51 min, p < 0.0005) and greater sleep efficiency (84 +/- 9% vs 78 +/- 11%, p < 0.0005) during polysomnography. CPAP titrations were improved in those receiving sedative/hypnotics, achieving lower respiratory disturbance index on the final CPAP pressure (6 +/- 7 vs 10 +/- 11, p = 0.04).nnnCONCLUSIONSnOf the measured variables, only age and a one-time use of sedative/hypnotics during polysomnography correlated with greater short-term CPAP compliance. Hypnotics facilitated better quality CPAP titrations. Reliable predictors of short-term CPAP use could help identify measures to improve long-term compliance.

Sleep disorders in combat-related PTSD

PurposeWe sought to assess the rate of sleep complaints and sleep disorders among active duty soldiers with deployment-related PTSD and to determine whether any clinical features differentiated those with sleep disorders.MethodsRetrospective review of consecutive soldiers diagnosed with PTSD. We recorded subjective measures of sleep and polysomnographic data. We compared clinical and demographic variables including psychoactive medication use, psychiatric comorbidity, and combat-related traumatic injury with the presence of sleep disorders.ResultsOne hundred thirty patients were included (91.5xa0% male, mean age of 35.1u2009±u200910.6xa0years, mean body mass index (BMI) 28.9u2009±u20094.4xa0Kg/m2). About 88.5xa0% had comorbid depression, with the majority (96.2xa0%) taking psychoactive medications (mean 3.4u2009±u20091.6 medications per patient). Over half of the cohort suffered combat-related traumatic physical injuries (54.6xa0%). The obstructive sleep apnea syndrome (OSAS) was diagnosed in 67.3xa0% (80xa0% of the cohort underwent polysomnography), with a mean apnea hypopnea index of 24.1u2009±u200922.8 events/hour and a mean oxygen saturation nadir of 84.2u2009±u20095.7xa0%. OSAS was significantly more common in the non-injured soldiers (72.9 vs. 38.0xa0%, pu2009<u20090.001). In multivariate analysis, absence of physical injury showed a trend towards predicting OSAS.ConclusionsSleep complaints are common among soldiers with PTSD. We observed significantly higher rates of OSAS among those without physical injuries, raising the possibility that underlying sleep-disordered breathing is a risk factor for the development of PTSD. This potential association requires further validation.

OSA Syndrome and Posttraumatic Stress Disorder: Clinical Outcomes and Impact of Positive Airway Pressure Therapy

BACKGROUNDnWe sought to determine the impact of OSA syndrome (OSAS) on symptoms and quality of life (QoL) among patients with posttraumatic stress disorder (PTSD). In addition, we assessed adherence and response to positive airway pressure (PAP) therapy in this population.nnnMETHODSnThis was a case-controlled observational cohort study at the Sleep Disorders Center of an academic military medical center. Two hundred consecutive patients with PTSD underwent sleep evaluations. Patients with PTSD with and without OSAS were compared with 50 consecutive age-matched patients with OSAS without PTSD and 50 age-matched normal control subjects. Polysomnographic data, sleep-related symptoms and QoL measures, and objective PAP usage were obtained.nnnRESULTSnAmong patients with PTSD, more than one-half (56.6%) received a diagnosis of OSAS. Patients with PTSD and OSAS had lower QoL and more somnolence compared with the other groups. Patients with PTSD demonstrated significantly lower adherence and response to PAP therapy. Resolution of sleepiness occurred in 82% of patients with OSAS alone, compared with 62.5% of PAP-adherent and 21.4% of nonadherent patients with PTSD and OSAS (P < .001). Similarly, posttreatment Functional Outcomes of Sleep Questionnaire ≥ 17.9 was achieved in 72% of patients with OSAS, compared with only 56.3% of patients with PTSD and OSA who were PAP adherent and 26.2% who were nonadherent (P < .03).nnnCONCLUSIONSnIn patients with PTSD, comorbid OSAS is associated with worsened symptoms, QoL, and adherence and response to PAP. Given the negative impact on outcomes, the possibility of OSAS should be considered carefully in patients with PTSD. Close follow-up is needed to optimize PAP adherence and efficacy in this at-risk population.

Maximizing Positive Airway Pressure Adherence in Adults: A Common-Sense Approach

Positive airway pressure (PAP) therapy is considered the most efficacious treatment of obstructive sleep apnea (OSA), especially moderate to severe OSA, and remains the most commonly prescribed. Yet suboptimal adherence presents a challenge to sleep-medicine clinicians. The purpose of the current review is to highlight the efficacy of published interventions to improve PAP adherence and to suggest a patient-centered clinical approach to enhancing PAP usage.

Clinical model for predicting prolonged mechanical ventilation.

INTRODUCTIONnMechanical ventilation (MV) predisposes patients to numerous complications, which increases with longer durations of treatment. Identifying individuals more likely to require prolonged MV (PMV) may alter ventilation strategies or potentially minimize the duration of therapy and its associated complications. Our aim was to identify clinical variables at the time of intubation that could identify individuals who will require PMV.nnnMETHODSnOne hundred thirty consecutive adult patients requiring MV support in a medical intensive care unit (ICU)were retrospectively assessed. Prolonged MV was defined as MV support more than 14 days.nnnRESULTSnMean age was 62.3±21.1 years, 64.6% were men, and mean duration of MV support was 11.4±11.9 days. Prolonged MV was required in 31.3%. Requiring intubation after admission to the ICU, heart rate greater than 110, blood urea nitrogen more than 25 mg/dL, serum pH less than 7.25, serum creatinine more than 2.0 mg/dL, and a HCO3 less than 20 mEq/L were the only variables independently associated with PMV. Specificity for predicting PMV was 100% with 4 or more of these variables.nnnCONCLUSIONnThe novel predictive model, using Intubation in the ICU, Tachycardia, Renal dysfunction, Acidemia, elevated Creatinine, and a decreased HCO3, was highly specific in identifying patients who subsequently required PMV support and performed better than Acute Physiology Age Chronic Health Evaluation III.

Sleep, sleep disorders, and mild traumatic brain injury. What we know and what we need to know: findings from a national working group

Disturbed sleep is one of the most common complaints following traumatic brain injury (TBI) and worsens morbidity and long-term sequelae. Further, sleep and TBI share neurophysiologic underpinnings with direct relevance to recovery from TBI. As such, disturbed sleep and clinical sleep disorders represent modifiable treatment targets to improve outcomes in TBI. This paper presents key findings from a national working group on sleep and TBI, with a specific focus on the testing and development of sleep-related therapeutic interventions for mild TBI (mTBI). First, mTBI and sleep physiology are briefly reviewed. Next, essential empirical and clinical questions and knowledge gaps are addressed. Finally, actionable recommendations are offered to guide active and efficient collaboration between academic, industry, and governmental stakeholders.

The Impact of Sleep on Soldier Performance

The military population is particularly vulnerable to a multitude of sleep-related disorders owing to the type of work performed by active duty servicemembers (ADSMs). Inadequate sleep, due to insufficient quantity or quality, is increasingly recognized as a public health concern. Traditionally, ADSMs have been encouraged that they can adapt to insufficient sleep just as the body adapts to physical training, but there is a substantial body of scientific literature which argues that this is not possible. Additionally, the military work environment creates unique challenges with respect to treatment options for common sleep disorders like obstructive sleep apnea, restless legs syndrome, and parasomnias. This review highlights sleep disorders which are prevalent in the modern military force and discusses the impact of poor sleep on overall performance. Medical treatments and recommendations for unit leaders are also discussed.

Health care rationing in the aged: ethical and clinical perspectives.

This article provides an ethical analysis of the question of whether aged patients’ access to health care should be less than, the same or greater than, the access younger patients enjoy, when economic resources are limited. This topic is being urgently considered in the US because managed care is becoming more common and brings with it new challenges to traditional medical ethics, and because the prevalence of the aged is increasing as is the number of patients with Alzheimer’s disease (AD). It is also critical throughout the world because new findings suggest that the progression of AD may be retarded or even reversed by providing patients with enriched interpersonal environments. If these findings are valid, it would be inhumane to not consider providing these resources to patients with AD, since these gains would be so meaningful and substantial.Deontological and consequential values influencing this question are presented and evaluated. The theories of Veatch, Callahan and Daniels in regard to allocating health care to the aged are discussed. It is argued that 2 subgroups of aged patients, the isolated and demented, are among the patients worst off because the capacity to enjoy meaningful relationships with others supercedes all others and both groups of patients have lost this capacity. We assert that, on the basis of the principle of justice according to need, these 2 groups of patients’ exceptional needs should be prioritised.We then raise the question of whether the majority of the population would be willing to provide these isolated and demented aged patients this care if the new findings proved valid. We conclude that, in light of many people’s fear of growing old and dying, and some peoples bias against the aged (particularly in the US), willingness to provide the necessary resources is open to debate.Finally, we provide specific examples of the kinds of interventions which might be optimal for each group of patients. For patients who are cognitively unimpaired, this might be providing home care so that they could remain closer to and in contact with their loved ones. For patients who are cognitively impaired, this might be providing interpersonal support when these patients begin to lose control, rather than applying restraints or using psychotropic medication.