Nalaka S. Gooneratne

A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions.

Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.

Functional outcomes of excessive daytime sleepiness in older adults

OBJECTIVES: To describe the effect of self‐reported excessive daytime sleepiness (EDS) on functional outcomes.

Age and Sleep Disturbances Among American Men And Women: Data From the U.S. Behavioral Risk Factor Surveillance System

STUDY OBJECTIVE Explore the prevalence of sleep-related complaints across age groups, examining effects of sex, general health, and depressed mood. DESIGN Cross-sectional analysis of data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS). SETTING Epidemiologic. PARTICIPANTS Complete-case analysis included 155,877 participants who responded to questions related to Self-Reported Sleep Disturbance (SLEEPDIST) and Self-Reported Tiredness/Lack of Energy (TIREDNESS). INTERVENTIONS None. MEASUREMENTS AND RESULTS Outcomes were self-reported complaints in response to survey questions assessing SLEEPDIST and TIREDNESS, dichotomized as reporting a complaint < 6 versus ≥ 6 nights or days, respectively, in a 2-wk period. Predictors were age, general health, and depressed mood. All analyses were adjusted for race/ethnicity, income, education, and time since last medical checkup. Across all age groups, women reported more SLEEPDIST and TIREDNESS. Poor general health, mild depressed mood, and moderate/severe depressed mood were associated with SLEEPDIST and TIREDNESS. Both SLEEPDIST and TIREDNESS generally declined across the life span, with fewest endorsements in respondents older than 80 yr. For SLEEPDIST, odds ratios (ORs, reference = 80+) declined from age 18-54 yr, rose slightly, and then declined again after age 59 yr in men. The pattern was similar for women, except a more marked rise was noted from age 40-59 yr. The pattern was similar for TIREDNESS. CONCLUSIONS Advancing age was not associated with increased Self-Reported Sleep Disturbance or Self-Reported Tiredness/Lack of Energy. These results suggest that the often-reported increase in sleep problems with age is a nonlinear phenomenon, mediated by factors other than physiologic aging.

Perceived Racial Discrimination as an Independent Predictor of Sleep Disturbance and Daytime Fatigue

Perceived discrimination is a potential cause of racial and ethnic disparities in health. Disturbed sleep may serve as a mechanism linking perceived racism with health consequences. This study investigates data from 7,148 adults from Michigan and Wisconsin who participated in the 2006 Behavioral Risk Factor Surveillance System. Hierarchical logistic regression analyses explored associations between perceived racial discrimination and self-reported sleep disturbance and daytime fatigue. Sleep disturbance and daytime fatigue were reported in 19% and 21% of the sample, respectively. Black/African American respondents (21%) report perceiving worse experiences, compared to people of other races, when seeking health care at higher rates than non-Hispanic White respondents (3%). Results from logistic regression models show that perceived racial discrimination is associated with increased risks of sleep disturbance (odds ratio [OR] = 2.62, p < .0001) and daytime fatigue (OR = 2.07, p < .0001). After adjustment for all covariates, perceived discrimination remains a significant predictor of sleep disturbance (OR = 1.60, p = .04). The interaction between perceived racism and race (Black/African American vs. non-Hispanic White) was nonsignificant. This population-based research adds to the growing body of data, suggesting that perceived racism may impact health via its influence on sleep-wake behaviors.

Chronic Obstructive Pulmonary Disease Diagnosis and Management in Older Adults

Chronic obstructive pulmonary disease (COPD) in older adults is a complex disorder with several unique age‐related aspects. Underlying changes in pulmonary lung function and poor sensitivity to bronchoconstriction and hypoxia with advancing age can place older adults at greater risk of mortality or other complications from COPD. The establishment of the Global Initiative for Obstructive Lung Disease criteria, which can be effectively applied to older adults, has more rigorously defined the diagnosis and management of COPD. An important component of this approach is the use of spirometry for disease staging, a procedure that can be performed in most older adults. The management of COPD includes smoking cessation, influenza and pneumococcal vaccinations, and the use of short‐ and long‐acting bronchodilators. Unlike with asthma, corticosteroid inhalers represent a third‐line option for COPD. Combination therapy is frequently required. When using various inhaler designs, it is important to note that older adults, especially those with more‐severe disease, may have inadequate inspiratory force for some dry‐powder inhalers, although many older adults find the dry‐powder inhalers easier to use than metered‐dose inhalers. Other important treatment options include pulmonary rehabilitation, oxygen therapy, noninvasive positive airway pressure, and depression and osteopenia screening. Clinicians caring for older adults with an acute COPD exacerbation should also guard against prognostic pessimism. Although COPD is associated with significant disability, there is a growing range of treatment options to assist patients.

Strength Training, Walking, and Social Activity Improve Sleep in Nursing Home and Assisted Living Residents: Randomized Controlled Trial

OBJECTIVES: To compare the effects of physical resistance strength training and walking (E), individualized social activity (SA), and E and SA (ESA) with a usual care control group on total nocturnal sleep time in nursing home and assisted living residents.

Melatonin pharmacokinetics following two different oral surge-sustained release doses in older adults

Abstract:  Melatonin is increasingly used for the treatment of sleep disorders. Surge‐sustained formulations consisting of combined immediate release and controlled release dosing may mimic the endogenous melatonin physiologic profile. However, relatively little is known about the pharmacokinetic properties of low‐dose (<0.5 mg) and high‐dose (>2 mg) melatonin in a combined immediate release/controlled release dose, especially in older adults who may also exhibit altered melatonin disposition. To assess this, we conducted a randomized, double‐blind, placebo‐controlled study of low‐dose (0.4 mg) and high‐dose (4.0 mg) melatonin (25% immediate release + 75% controlled release) in 27 older adults with insomnia complaints and low endogenous melatonin levels to determine whether melatonin pharmacokinetic properties differ between these two doses. The time to maximum level (1.3 hrs versus 1.5 hrs), elimination half‐life (1.8 hrs versus 2.1 hrs), and apparent total clearance (379 L/hr versus 478 L/hr) did not differ significantly between the low‐ and high‐dose arms, respectively. The maximum concentration was 405 ± 93 pg/mL for the low‐dose arm and 3999 ± 700 pg/mL for the high‐dose arm, both of which are substantially higher than physiologic melatonin levels for this age group. In addition, subjects in the high‐dose arm maintained melatonin levels >50 pg/mL for an average of 10 hrs, which could result in elevated melatonin levels beyond the typical sleep period. Renal and liver function parameters remained stable after 6 wks of treatment. The linear pharmacokinetic behavior of melatonin observed in the elderly can form the basis for future studies exploring a wider range of dosing scenarios to establish exposure–response relationships for melatonin‐mediated sleep outcomes.

Sleep disturbances and nocturnal agitation behaviors in older adults with dementia.

STUDY OBJECTIVES To examine nighttime sleep patterns of persons with dementia showing nocturnal agitation behaviors and to determine whether restless legs syndrome (RLS), periodic limb movements in sleep (PLMS), and obstructive sleep apnea (OSA) are associated with nocturnal agitation behaviors. DESIGN Cross-sectional. SETTING General community. PARTICIPANTS 59 participants with geriatrician-diagnosed dementia. Participants ages ranged from 66 to 88 years (mean age 79.1; SD 6.0). Mean Mini Mental State Examination (MMSE) score was 20.1 (SD 6.6). MMSE was used to measure baseline cognitive function and not for the diagnosis of dementia. INTERVENTIONS None. MEASUREMENTS AND RESULTS Sleep was measured by 2 nights of in-home, attended, portable polysomnography (PSG). Nocturnal agitation was measured over 3 additional nights using the Cohen-Mansfield Agitation Inventory modified for direct observations. Two experts independently and via consensus identified probable RLS. Total sleep time in participants was 5.6 h (SD 1.8 h). Mean periodic limb movements in sleep index (PLMI) was 15.29, and a high percentage (49%) had moderate to severe obstructive sleep apnea. Probable RLS was present in 24% of participants. Those with more severe cognitive impairment had longer sleep latency. Severe cognitive impairment, low apnea hypopnea index (AHI), and probable RLS were associated with nocturnal agitation behaviors (R(2) = 0.35, F(3,55) = 9.40, P < 0.001). CONCLUSIONS It appears that probable RLS is associated with nocturnal agitation behaviors in persons with dementia, while OSA and PLMS are not. Further investigation is warranted to determine if treatment of RLS impacts nocturnal agitation behaviors in persons with dementia.

Sleep In Older Adults: Normative Changes, Sleep Disorders, and Treatment Options

Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. It is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter having associated daytime impairments. Non-pharmacologic therapies, such as cognitive-behavioral therapy for insomnia, can be highly effective with sustained benefit. Pharmacologic therapies are also available, but may be associated with psychomotor effects. A high index of suspicion is crucial for effective diagnosis of sleep apnea because symptoms commonly noted in younger patients, such as obesity or loud snoring, may not be present in older patients.

Single slice vs. volumetric MR assessment of visceral adipose tissue: reliability and validity among the overweight and obese.

Visceral adipose tissue (VAT) is associated with abnormal cardiovascular and metabolic profiles. Total VAT volume of the abdominal compartment by magnetic resonance imaging (MRI) is the gold‐standard measurement for VAT but is costly and time consuming. Prior studies suggest VAT area on a single slice MR image may serve as a surrogate for total VAT volume but it is unknown if this relationship is maintained in overweight and obese men and women. Untreated sleep apnea subjects enrolled into the Icelandic Sleep Apnea Cohort (ISAC) underwent abdominal MRI. VAT area and subcutaneous adipose tissue (SAT) area at the L2‐L3 and L4‐L5 interspaces and total VAT and SAT volumes were determined by manual examination using image analysis software; 539 men and 129 women with mean ages of 54.1 and 58.8 years and mean BMI of 32.2 kg/m2 and 33.7 kg/m2, respectively, were studied. Mean total VAT volume was 40% smaller and mean total SAT was 25% larger among females compared with males. The correlation with VAT volume was significantly larger for L2‐L3 VAT area (r = 0.96) compared to L4‐L5 VAT area (r = 0.83). The difference in correlation coefficients was statistically significant (nonparametric bootstrap P < 0.001 with 95% confidence interval (CI) for the difference from 0.11 to 0.15. VAT area at L2‐L3 was also significantly better correlated with VAT volume than traditional anthropometric variables. Linear regression analyses demonstrated that L2‐L3 area alone was sufficient for predicting total VAT volume and that the nature of the linear association was maintained across all levels of obesity and in both genders.