Emerson M. Wickwire

Sleep maintenance insomnia complaints predict poor CPAP adherence: A clinical case series

BACKGROUND Although CPAP is a highly efficacious treatment for obstructive sleep apnea (OSA), low adherence presents a significant challenge for sleep medicine clinicians. The present study aimed to evaluate the relationship between insomnia symptoms and CPAP use. We hypothesized that pre-treatment insomnia complaints would be associated with poorer CPAP adherence at clinical follow-up. METHODS This was a retrospective chart review of 232 patients (56.5% men, mean age=53.6+/-12.4years) newly diagnosed with OSA (mean AHI=41.8+/-27.7) and prescribed CPAP in the Johns Hopkins Sleep Disorder Center. Difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening were measured via three self-report items. CPAP use was measured via objective electronic monitoring cards. RESULTS Thirty-seven percent of the sample reported at least one frequent insomnia complaint, with 23.7% reporting difficulty maintaining sleep, 20.6% reporting early morning awakening and 16.6% reporting difficulty initiating sleep. After controlling for age and gender, sleep maintenance insomnia displayed a statistically significant negative relationship with average nightly minutes of CPAP use (p<.05) as well as adherence status as defined by the Centers for Medicaid and Medicare Services (p<.02). CONCLUSIONS To our knowledge, these are the first empirical data to document that insomnia can be a risk factor for poorer CPAP adherence. Identifying and reducing insomnia complaints among patients prescribed CPAP may be a straightforward and cost-effective way to increase CPAP adherence.

Insomnia and Sleep-Related Breathing Disorders

Insomnia disorder and obstructive sleep apnea are the two most common sleep disorders among adults. Historically, these conditions have been conceptualized as orthogonal, or insomnia has been considered a symptom of sleep apnea. Insomnia researchers have sought to exclude participants at risk for sleep-related breathing disorders (SRBD), and vice versa. In recent years, however, there has been a growing recognition of co-occurring insomnia disorder and SRBD and interest in the prevalence, consequences, and treatment of the two conditions when they co-occur. Although plagued by inconsistent diagnostic criteria and operational definitions, evidence from clinical and research samples consistently suggests high rates of comorbidity between the two disorders. More important, insomnia disorder and SRBD have additive negative effects. To date, only a few studies have explored the combined or sequential treatment of the conditions. Results support the importance of an integrated, interdisciplinary approach to sleep medicine. This article reviews the empirical literature to date and provides clinical recommendations as well as suggestions for future research.

National Sleep Foundation's sleep quality recommendations: first report

Objectives: To provide evidence‐based recommendations and guidance to the public regarding indicators of good sleep quality across the life‐span. Methods: The National Sleep Foundation assembled a panel of experts from the sleep community and representatives appointed by stakeholder organizations (Sleep Quality Consensus Panel). A systematic literature review identified 277 studies meeting inclusion criteria. Abstracts and full‐text articles were provided to the panelists for review and discussion. A modified Delphi RAND/UCLA Appropriateness Method with 3 rounds of voting was used to determine agreement. Results: For most of the sleep continuity variables (sleep latency, number of awakenings >5 minutes, wake after sleep onset, and sleep efficiency), the panel members agreed that these measures were appropriate indicators of good sleep quality across the life‐span. However, overall, there was less or no consensus regarding sleep architecture or nap‐related variables as elements of good sleep quality. Conclusions: There is consensus among experts regarding some indicators of sleep quality among otherwise healthy individuals. Education and public health initiatives regarding good sleep quality will require sustained and collaborative efforts from multiple stakeholders. Future research should explore how sleep architecture and naps relate to sleep quality. Implications and limitations of the consensus recommendations are discussed.

Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: a cross-lagged panel analysis.

&NA; An increasing number of prospective studies suggest a bi‐directional association between the pain and sleep quality. Few of these investigations have controlled for synchronous correlations, an important source of extraneous variance in lagged associations, which may have confounded conclusions of prior investigations. Despite high rates of insomnia in temporomandibular joint disorders (TMD), no studies have examined temporal associations between naturalistic fluctuations in insomnia and pain in TMD. We conducted cross‐lagged panel analysis to examine reciprocal temporal associations between 1‐month changes in insomnia symptom severity and self‐reported pain over 3 months among 53 TMD patients. This rigorous analytic strategy represents a comprehensive method to explore possible reciprocal temporal associations between insomnia and pain that controls for both auto‐ and synchronous correlations. Analyses revealed that initial‐month increases in insomnia were associated with next‐month increases in average daily pain, but not vice versa. The direction of the effect was such that initial‐month increases in insomnia symptom severity were associated with next‐month increases in average daily pain. These data suggest that naturally occurring fluctuations in insomnia symptom severity are prospectively associated with fluctuations in daily pain experience for persons with TMD. Potential mechanisms by which insomnia might influence pain in TMD and therapeutic implications of these findings are discussed.

Outcome Expectancies and Gambling Behavior Among Urban Adolescents

This project sought to identify adolescent outcome expectancies for gambling and to evaluate their relation to gambling behavior among a sample of urban adolescents. In a preliminary study, 50 outcome expectancies were identified on the basis of a literature review or generated after surveying 35 urban high school students. These expectancies were then administered to 1,076 urban high school students. Rates of at-risk and problem gambling were 14.6% and 12.7%, respectively. Exploratory and confirmatory factor analyses were performed on randomly selected halves of the sample and identified 5 expectancy domains. In a structural equation model, material gain, negative affect, and positive self-evaluation displayed significant positive relations, and negative social consequences and parent disapproval displayed significant negative relations, to gambling behavior. The model explained 48% of the variance in gambling problems and 58% of the variance in gambling frequency. These results demonstrate the salience of gambling-related cognitions in understanding the gambling behavior among these at-risk youth and suggest that expectancies may be important prevention targets for this population.

Health economics of insomnia treatments: The return on investment for a good night's sleep

Chronic insomnia is the most common sleep disorder among adults and is associated with a wide range of negative outcomes. This article reviews the economic consequences of the disorder and the cost effectiveness of insomnia treatments. First, the total costs of insomnia are reviewed; in aggregate these costs exceed

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

100 billion USD per year, with the majority being spent on indirect costs such as poorer workplace performance, increased health care utilization, and increased accident risk. Next, the deleterious impact of insomnia on quality of life and the impact of treatment on quality of life are briefly considered. Finally, ten published studies evaluating the cost effectiveness of both pharmacological and behavioral treatments for insomnia are reviewed in detail. A significant majority of studies reviewed found that the cost of treating primary and comorbid insomnia is less than the cost of not treating it. Treatments were generally found to be cost-effective using commonly employed standards, with treatment costs being recouped within 6-12 mo.

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

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.

Combined Insomnia and Poor CPAP Compliance A Case Study and Discussion

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.

Shift Work and Shift Work Sleep Disorder: Clinical and Organizational Perspectives

This report describes the case of Samuel, a Caucasian man in his early sixties who self-referred to a behavioral insomnia clinic at a university medical center. Samuel had recently been diagnosed with obstructive sleep apnea and had been prescribed continuous positive air pressure (CPAP) therapy for this condition. At the time he presented for treatment, he was non-compliant with his CPAP prescription and maintained that the physician who diagnosed obstructive sleep apnea was mistaken. His presenting complaint to the insomnia clinic was a 25-year history of difficulty initiating sleep, which he believed was the sole cause of his problem with daytime sleepiness. In addition to his obstructive sleep apnea, Samuel was diagnosed with obstructive sleep apnea and psychophysiological insomnia. The treatments selected were a motivational enhancement treatment for CPAP compliance and a cognitive-behavioral intervention for insomnia. Treatments were presented in a combined, sequential fashion. At treatment follow-up, Samuel reported increased CPAP compliance, decreased daytime sleepiness, and decreased insomnia severity.