Martin Ulander

Association of Type D personality to perceived side effects and adherence in CPAP-treated patients with OSAS.

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but side effects are common and long‐term adherence low. The Type D (distressed) personality is defined as a combination of negative affectivity and social inhibition. The association of Type D personality with adherence has not been studied in CPAP‐treated patients with OSAS. This study aimed to describe the prevalence of Type D personality in OSAS patients with CPAP treatment longer than 6 months and the association with self‐reported side effects and adherence. A cross‐sectional descriptive design was used. A total of 247 OSAS patients with a mean use of CPAP treatment for 55 months (6–182 months) were included. Data collection was achieved by two questionnaires; the Type D scale 14 (DS14) (Type D personality), SECI (side effects of CPAP), as well as from medical records (clinical variables and objective adherence to CPAP treatment). Type D personality occurred in 30% of the patients with OSAS and significantly (P < 0.05–0.001) increased the perceived frequency and severity of a broad range of side effects. The objective adherence was significantly lower (P < 0.001) for OSAS patients with Type D compared to OSAS patients without Type D, both with regard to a mean use of 4 h per night and 85% of the self‐rated sleep time per night. The additional effect of a Type D personality on perceived side effects and adherence to CPAP treatment found in this study could be used by healthcare personnel when evaluating patients waiting for treatment.

Perceived informational needs, side-effects and their consequences on adherence—A comparison between CPAP treated patients with OSAS and healthcare personnel

OBJECTIVE To compare perceptions among continuous positive airway pressure (CPAP) treated patients with obstructive sleep apnoea syndrome (OSAS) and healthcare personnel with regard to informational needs, side-effects and their consequences on adherence. METHODS A cross-sectional descriptive design was used including 350 CPAP treated OSAS patients from three Swedish hospitals and 105 healthcare personnel from 26 Swedish hospitals. Data collection was performed using two questionnaires covering informational needs, side-effects and adherence to CPAP. RESULTS Both groups perceived all surveyed informational areas as very important. Patients perceived the possibilities to learn as significantly greater in all areas (p<0.001) compared to healthcare personnel, and scored significantly higher regarding positive effects on adherence of information about pathophysiology (p<0.05), self-care (p<0.001) and troubleshooting (p<0.01). A total of 11 out of 15 surveyed side-effects were perceived to be more frequent by healthcare personnel (p<0.01-p<0.001). They also scored all side-effects to cause greater problems and decrease the CPAP use to a greater extent (p<0.001). CONCLUSION Knowledge about these differences between patients and healthcare personnel regarding educational needs, side-effects and their effects on adherence can be important when designing educational programmes to increase CPAP adherence. PRACTICE IMPLICATIONS Measurement of these parameters before, during and after educational programs are suggested.

The side-effects to CPAP treatment inventory: the development and initial validation of a new tool for the measurement of side-effects to CPAP treatment

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but side‐effects are common. No validated self‐rating scale measuring side‐effects to CPAP treatment exists today. The aim was to develop the side‐effects to CPAP treatment inventory (SECI), and investigate the validity and reliability of the instrument among patients with OSAS. SECI was developed on the basis of: (1) in‐depth interviews with 23 patients; (2) examination of the scientific literature and (3) consensus agreement of a multi‐professional expert panel. This yielded 15 different types of side‐effects related to CPAP treatment. Each side‐effect has three sub‐questions (scales): perceived frequency (a) and magnitude (b) of the side‐effect, as well as its perceived impact on CPAP use (c). A cross‐sectional descriptive design was used. A total of 329 patients with OSAS with an average use of CPAP treatment for 39 months (2 weeks to 182 months) were recruited. Data were collected with SECI, and obtained from medical records (clinical variables and data related to CPAP treatment). Construct validity was confirmed with factor analysis (principal component analysis with orthogonal rotation). A logical two‐factor solution, the device subscale and symptom subscale, emerged across all three scales. The symptom subscale describing physical and psychological side‐effects and the device subscale described mask and device‐related side‐effects. Internal consistency reliability of the three scales was good (Cronbach’s α = 0.74–0.86) and acceptable for the subscales (Cronbach’s α = 0.62–0.86). The satisfactory measurement properties of this new instrument are promising and indicate that SECI can be used to measure side‐effects to CPAP treatment.

Factors associated with undiagnosed obstructive sleep apnoea in hypertensive primary care patients

Abstract Objective. In hypertensive primary care patients below 65 years of age, (i) to describe the occurrence of undiagnosed obstructive sleep apnoea (OSA), and (ii) to identify the determinants of moderate/severe OSA. Design. Cross-sectional. Setting. Four primary care health centres in Sweden. Patients. 411 consecutive patients (52% women), mean age 57.9 years (SD 5.9 years), with diagnosed and treated hypertension (BP >140/90). Main outcome measures. Occurrence of OSA as measured by the apnoea hypopnoea index (AHI). Results. Mild (AHI 5–14.9/h) and moderate/severe (AHI > 15/h) OSA were seen among 29% and 30% of the patients, respectively. Comparing those without OSA with those with mild or moderate/severe OSA, no differences were found in blood pressure, pharmacological treatment (anti-hypertensive, anti-depressive, and hypnotics), sleep, insomnia symptoms, daytime sleepiness, or depressive symptoms. Obesity (BMI > 30 kg/m2) was seen in 30% and 68% of the patients with mild and moderate/severe OSA, respectively. Male gender, BMI > 30 kg/m2, snoring, witnessed apnoeas, and sleep duration >8 hours were determinants of obstructive sleep apnoea. Conclusion. Previously undiagnosed OSA is common among patients with hypertension in primary care. Obesity, snoring, witnessed apnoeas, long sleep duration, and male gender were the best predictors of OSA, even in the absence of daytime sleepiness and depressive symptoms.

Occurrence of epileptiform discharges and sleep during EEG recordings in children after melatonin intake versus sleep-deprivation

OBJECTIVE To determine if melatonin is equally efficient as partial sleep deprivation in inducing sleep without interfering with epileptiform discharges in EEG recordings in children 1-16 years old. METHODS We retrospectively analysed 129 EEGs recorded after melatonin intake and 113 EEGs recorded after partial sleep deprivation. Comparisons were made concerning occurrence of epileptiform discharges, the number of children who fell asleep and the technical quality of EEG recordings. Comparison between different age groups was also made. RESULTS No significant differences were found regarding occurrence of epileptiform discharges (33% after melatonin intake, 36% after sleep deprivation), or proportion of unsuccessful EEGs (8% and 10%, respectively). Melatonin and sleep deprivation were equally efficient in inducing sleep (70% in both groups). Significantly more children aged 1-4 years obtained sleep after melatonin intake in comparison to sleep deprivation (82% vs. 58%, p⩽0.01), and in comparison to older children with melatonin induced sleep (58-67%, p⩽0.05). Sleep deprived children 9-12 years old had higher percentage of epileptiform discharges (62%, p⩽0.05) compared to younger sleep deprived children. CONCLUSION Melatonin is equally efficient as partial sleep deprivation to induce sleep and does not affect the occurrence of epileptiform discharges in the EEG recording. Sleep deprivation could still be preferable in older children as melatonin probably has less sleep inducing effect. SIGNIFICANCE Melatonin induced sleep have advantages, especially in younger children as they fall asleep easier than after sleep deprivation. The procedure is easier for the parents than keeping a young child awake for half the night.

Altered Brain Microstate Dynamics in Adolescents with Narcolepsy

Narcolepsy is a chronic sleep disorder caused by a loss of hypocretin-1 producing neurons in the hypothalamus. Previous neuroimaging studies have investigated brain function in narcolepsy during rest using positron emission tomography (PET) and single photon emission computed tomography (SPECT). In addition to hypothalamic and thalamic dysfunction they showed aberrant prefrontal perfusion and glucose metabolism in narcolepsy. Given these findings in brain structure and metabolism in narcolepsy, we anticipated that changes in functional magnetic resonance imaging (fMRI) resting state network (RSN) dynamics might also be apparent in patients with narcolepsy. The objective of this study was to investigate and describe brain microstate activity in adolescents with narcolepsy and correlate these to RSNs using simultaneous fMRI and electroencephalography (EEG). Sixteen adolescents (ages 13–20) with a confirmed diagnosis of narcolepsy were recruited and compared to age-matched healthy controls. Simultaneous EEG and fMRI data were collected during 10 min of wakeful rest. EEG data were analyzed for microstates, which are discrete epochs of stable global brain states obtained from topographical EEG analysis. Functional MRI data were analyzed for RSNs. Data showed that narcolepsy patients were less likely than controls to spend time in a microstate which we found to be related to the default mode network and may suggest a disruption of this network that is disease specific. We concluded that adolescents with narcolepsy have altered resting state brain dynamics.

How active are patients with idiopathic normal pressure hydrocephalus and does activity improve after shunt surgery? A controlled actigraphic study

INTRODUCTION Actigraphy allows long-time evaluation of physical activity and resting behaviour in a normal environment. The aim of this study was, by use of actigraphy, to measure motor function, energy expenditure and resting/sleeping time in idiopathic normal pressure hydrocephalus (iNPH) patients before and after surgery, and compare the results with healthy individuals (HI). SUBJECTS AND METHODS 33 patients (mean 73 year) and 17 HI (mean 73 year) participated. Actigraphy with SenseWear (BodyMedia Inc., Pittsburgh, PA, USA) was recorded in the iNPH patients before and three months postoperatively and twice in the HI with a three-month interval. In addition, gait speed, timed up and Go (TUG) and MMSE were registered pre- and post-operatively. RESULTS During daytime the patients took fewer steps (p < 0.001) and their total energy expenditure (TEE) was lower (p < 0.01) than in the HI. Twenty patients were evaluated pre- and post-operatively and no change in either the number of steps, TEE, or time spent lying/sleeping after surgery could be detected. iNPH patients had lower gait speed, worse TUG and MMSE compared to the HI. Gait and TUG improved after surgery. CONCLUSION Actigraphy in iNPH patients indicated reduced ambulatory activity and lower energy expenditure compared to HI preoperatively. This did not change postoperatively in spite of improved TUG and gait speed.

The attitudes to CPAP treatment inventory: development and initial validation of a new tool for measuring attitudes to CPAP treatment

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but low adherence rates are common. The aim was to develop the attitudes to CPAP treatment inventory (ACTI), and to investigate the validity and reliability of the instrument among patients with OSAS. ACTI was developed on the basis of: (i) in‐depth interviews with 23 patients; (ii) examination of the scientific literature; and (iii) consensus agreement of a multi‐professional expert panel. This yielded five different types of attitudes to CPAP treatment. A prospective longitudinal design was used. Two‐hundred and eighty‐nine patients with OSAS were recruited at three different CPAP centres. Data were collected with ACTI and obtained from medical records. The homogeneity and internal consistency reliability were satisfactorily reflected by the item‐total correlations (0.59–0.81) and Cronbach’s alpha (0.89), respectively. Construct validity was confirmed with factor analysis (principal component analysis with orthogonal rotation; PCF). The PCF based on baseline data resulted in a one single‐factor solution explaining 69% of the total variance. A confirmatory factor analysis was performed 2 weeks after CPAP initiation, resulting in the same factor solution. No indication of uniform differential item functioning was found. The predictive validity was tested with receiver operating characteristic analyses, and a cut‐off of 10 on the ACTI gave a sensitivity of 93% and a specificity of 44% for CPAP termination within 6 months. The satisfactory measurement properties of this new pragmatic instrument are promising and indicate that ACTI can be useful in clinical practice to reliably measure attitudes to CPAP treatment.

Gender differences in respiratory disturbance, sleep and daytime sleepiness in hypertensive patients with different degrees of obesity

Background: Hypertension (HT) and obesity have both been linked to obstructive sleep apnoea (OSA). Difficulties have been described in identifying patients with OSA in primary care, causing low referral rates to sleep clinics. Increased knowledge about gender-specific characteristics and symptoms may help to identify patients. Aim: The aim was to describe gender differences regarding undiagnosed OSA, self-rated sleep, insomnia and daytime sleepiness in middle-aged primary care patients with HT and different degrees of obesity. Methods: A cross-sectional design was used and 394 patients (52.5% women), mean age 57.8 years (SD 6.7 years), with HT (BP >140/90 mmHg) were included. Clinical examinations, respiratory recordings and self-rated scales regarding OSA symptoms, sleep, insomnia and daytime sleepiness were used. Body mass index (BMI) was classified according to the criteria from the National Institutes of Health. Results: Pre-obesity and obesity classes I and II were seen among 53%, 26% and 8% of the men and 37%, 19% and 14% of the women, respectively. Occurrence of mild, moderate and severe OSA increased significantly across the BMI classes for both genders (p<0.01). Ninety percent of the men and 80% of the women in obesity class II had OSA. Insomnia was prevalent in obese patients. Other clinical variables did not differ between BMI classes or genders. Conclusion: The occurrence of overweight/obesity and OSA was high among both genders. A high BMI might be a convenient clinical marker for healthcare personnel to identify hypertensive patients with possible OSA in need of further evaluation and treatment.

Traffic risk work with sleepy patients: from rationality to practice

In this article, we aim to contribute to the emerging field of risk-work studies by examining the relationship between risk rationality and risk practices in nurses’ conversations with Obstructive Sleep Apnoea patients about traffic risks. Legislation in Sweden towards traffic risk involves clinicians making risk assessment of patients prone to falling asleep while driving. In contrast to an overall care rationale, this means that the health of the patient is not the only risk object in treatment consultations. However, guidelines on how to implement legislation are missing. To examine the practical reality of nurses’ traffic-risk work, we draw on an analysis of data from a Swedish study in 2015. This study included qualitative interviews with specialist nurses and video-recorded interactions between nurses and Obstructive Sleep Apnoea patients. We found that a lack of clarity in traffic-risk guidelines on how risk should be addressed was evident in both interview accounts and in observed practice. While nurses primarily accounted for risk work as treatment-relevant education, they practised risk work as interrogation. Patients also treated nurses’ inquiries as assessment – not education – by responding defensively. We conclude that while confusing risk work and treatment enables clinicians to treat patients as competent actors, it obscures the controlling aspects of traffic-risk questions for individual patients and downplays the implications of drowsy driving for general traffic safety.