Shyam Subramanian

Gender and ethnic differences in prevalence of self-reported insomnia among patients with obstructive sleep apnea

BackgroundInsomnia and obstructive sleep apnea (OSA) are the two most common sleep disorders. Studies have shown that complaints of insomnia are prevalent among sleep clinic patients evaluated for OSA. Less is known about the gender and ethnic variations in this association.ObjectivesThis paper aims to study the influence of gender and ethnicity in the prevalence of insomnia in patients with OSA and explore the association between these two disorders with an emphasis on psychophysiologic insomnia.Methods and measurementsWe reviewed case files, including self-reported questionnaires and polysomnography studies of 300 OSA patients [apnea–hypopnea index (AHI) of >10] from three ethnic groups—Caucasian, Hispanic, and African American, 50 patients each, male and female, seen at a tertiary care county hospital adult sleep center. Self-reported insomnia was classified as sleep onset insomnia, sleep maintenance insomnia, or insomnia with early morning awakening. Psychophysiologic insomnia was documented if the patient reported two of the following five symptoms: racing thoughts when trying to sleep, increased muscle tension when trying to sleep, fear of being unable to sleep, fear of being unable to fall back to sleep after waking up, and lying in bed worrying. Fischer exact tests for each contingency table were run using SPSS.ResultsAmong OSA patients, women were older, had higher body mass index, and lower AHI at the time of diagnosis, compared to men. Insomnia was more prevalent among patients with OSA (84%) than the reported 30% among general adult population. Sleep onset insomnia was reported more frequently by women (62%) than men (53%) (p = 0.03). Similarly self-reported psychophysiologic insomnia also showed a female preponderance (53% vs. 45%, p = 0.03). Caucasian women had the highest rate of self-reported sleep maintenance insomnia (80%). Hispanic women are more likely to complain of symptoms suggestive of psychophysiologic insomnia (58%).ConclusionsThere is a higher prevalence of insomnia in OSA patients. Ethnicity and gender possibly exhibit a complex and significant influence on the reported subtype of insomnia. Further larger studies may help confirm, as well as clarify, mechanisms that underlie the ethnic and gender differences that we have noted.

Air Leak Is Associated With Poor Adherence to AutoPAP Therapy

STUDY OBJECTIVES To our knowledge, a systematic study of the effect of air leak on adherence to auto-titrating positive airway pressure (autoPAP) therapy has not been reported. We hypothesized that in patients with obstructive sleep apnea (OSA), greater levels of air leak were associated with poor adherence to autoPAP therapy. DESIGN Retrospective cohort study SETTING Academic Center PARTICIPANTS Ninety-six consecutive patients with high probability for OSA. INTERVENTIONS N/A. MEASUREMENTS Patients with OSA received 1 week of autoPAP therapy following which both adherence data and air leak information was downloaded from the device. Continuous positive airway pressure (CPAP) therapy was issued for a 5-week period with pressure determined by 90th percentile of that delivered during autoPAP therapy. Adequate adherence was defined as average usage > 4 h per night on all nights. RESULTS Forty-three patients were adherent to autoPAP therapy (350 ± 67[SD] min/day), whereas 53 patients were not (122 ± 65 min/day; P < 0.0001). Air leak that was adjusted for pressure delivered was greater in non-adherent patients (7.0 ± 3.5 L/min/cm H(2)O) than that in adherent patients (4.9 ± 1.7 L/min/cm H(2)O; P < 0.0001). Greater residual respiratory events (measured as autoPAP-derived hypopnea index) and proportion of time spent at large leak levels were associated with non-adherence. Patients who were adherent to autoPAP therapy received higher average therapeutic pressures from the autoPAP device than non-adherent patients. Multivariate logistic regression revealed that higher levels of air leak were associated with non-adherence to autoPAP therapy (odds ratio 1.43; 95% CI, 1.03, 1.98; P = 0.03). Moreover, adherence to autoPAP therapy was strongly correlated with subsequent adherence to CPAP therapy (R(2) = 0.74; P < 0.0001). CONCLUSION Air leak was associated with poor adherence to autoPAP therapy. We speculate that air leak could be a potential target for future studies aimed at enhancing adherence to autoPAP therapy.

A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea

OBJECTIVES To study the effect of sleep center accreditation and Sleep Medicine board certification of physicians on patient-centered outcomes in obstructive sleep apnea (OSA). DESIGN Prospective, multicenter, comparative effectiveness study. SETTING Four sleep centers. PATIENTS 502 patients with OSA. INTERVENTIONS None. MEASUREMENTS AND RESULTS Patients at two accredited and two non-accredited centers underwent polysomnography at participating locations and completed validated questionnaires, with objective measurement of positive airway pressure (PAP) therapy adherence performed three months after therapy initiation. The proportion of patients (age 53 ± 13[SD] years; 26% women; and body mass index 33.6 ± 7.2 kg/m(2)) who were adherent to PAP therapy by Medicare guidelines (> 70% of nights with ≥ 4 h use over a 30-day period) was greater in accredited (79%) than non-accredited sites (64%; p = 0.004). After adjustment for confounding variables, patients who received care from accredited centers (odds ratio [OR] 2.2, 95% confidence interval [CI], 1.2-4.2; p = 0.016) and certified physicians (OR 2.3, 95% CI, 1.3-4.0; p = 0.005) were more likely to be adherent to PAP therapy than those who received care from non-accredited centers and non-certified physicians. Patient satisfaction was associated with greater education received from physician (OR 4.6; 95% CI 2.3-9.3); greater risk perception (OR 2.7; 95% CI 1.0-7.4); physician certification (OR 2.1; 95% CI 1.1-4.2); and inversely related to delays in care (OR 0.5; 95% CI 0.3-0.9; p < 0.05). Such delays were inversely related to accreditation-certification status (p < 0.0001). CONCLUSIONS In patients with OSA, accreditation-certification status of sleep centers and physicians was associated with better PAP adherence, better patient education, better patient satisfaction, and greater timeliness. COMMENTARY A commentary on this article appears in this issue on page 251. CITATION Parthasarathy S; Subramanian S; Quan SF. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea.

Sexual dysfunction in women with obstructive sleep apnea.

BackgroundFemale sexual dysfunction is vastly under-recognized but has been previously described in chronic disease states. Sexual dysfunction in male patients with obstructive sleep apnea (OSA) is well described, but not in females.ObjectiveThe objective of this study was to assess the prevalence of sexual dysfunction in women with OSA.MethodsWe studied 21 consecutive pre-menopausal women with OSA, referred to our sleep lab, and who had a positive study for sleep apnea (respiratory disturbance index (RDI) > 5), and 11 healthy pre-menopausal women were included as the control group. Subjects were administered the Female Sexual Function Index (FSFI) questionnaire and a mood scale—Profile of Mood States.ResultsOf the study group, 11 women (52.4%) had FSFI scores in the poor range (<23) as compared to the control group, in which none of the women (0%) had FSFI scores in the poor range (<23). Negative mood domain scores were not different in patients with poor FSFI compared to patients with normal FSFI scores. There was no correlation between obesity, severity of sleep apnea, or mood disorders on overall scores of sexual dysfunction. Among individual domains, there was a correlation between RDI and arousal scores.ConclusionIn our study, we have found that prevalence of sexual dysfunction is high among women with OSA. Physicians should routinely screen and evaluate women with OSA for sexual dysfunction.

Practice patterns of screening for sleep apnea in physicians treating PCOS patients

Women with polycystic ovarian syndrome (PCOS) have been shown to have a very high prevalence of obstructive sleep apnea (OSA). Screening for OSA is recommended for PCOS patients. How far this is carried out in actual practice is unknown. To study practice patterns with regard to screening for OSA in physicians—both obstetrician/gynecologists (ObGyn) and endocrinologist—who manage PCOS. A secondary aim of this study was to identify practice differences, if any. Two hundred ObGyn and 140 endocrine academic institutions were contacted and mailed with questionnaires, if willing to participate. Responses were obtained from 50 (29.4%) ObGyn physicians and 29 (26.4%) endocrine physicians. The questionnaire was closed-ended. Physicians reported a high occurrence of obesity—36.7% of the physicians reported that 75–100% of their patients had morbid obesity. However, reported prevalence of symptoms was low—86.1% of the physicians felt their patients snored infrequently (<25% of the time) and 74.7% felt that their patients had excess daytime sleepiness (EDS) infrequently. Of the physicians, 92.4% ordered a sleep study <25% of the time. No significant difference in practice between the specialties was identified. Physicians who manage PCOS patients do not believe that these patients have significant symptoms nor warrant frequent testing for OSA. This may reflect lack of knowledge about the link or may imply that PCOS patients remain largely asymptomatic. Educating specialist physicians managing PCOS about OSA and improved tools for OSA screening may improve detection.

Effect of continuous positive airway pressure therapy on glucose control

Obstructive sleep apnea (OSA) and diabetes mellitus are both highly prevalent disorders. There has been a recent recognition of an association between insulin resistance and sleep apnea. Continuous positive airway pressure (CPAP) has emerged as an effective therapy for treatment of OSA and has been shown to positively influence numerous pathophysiological factors that contribute to cardiovascular risk. There is emerging data that explores the influence of CPAP therapy, insulin sensitivity and glycemic control. In the current review, we examine this literature critically and formulate a synopsis that summarizes the current knowledge in this field.

The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea

PurposeObstructive sleep apnea (OSA) remains underdiagnosed, despite our understanding of its impact on general health. Current screening methods utilize either symptoms or physical exam findings suggestive of OSA, but not both. The purpose of this study was to develop a novel screening tool for the detection of OSA, the NAMES assessment (neck circumference, airway classification, comorbidities, Epworth scale, and snoring), combining self-reported historical factors with physical exam findings.MethodsSubjects were adults without previously diagnosed OSA, referred to a community sleep center for suspicion of OSA. General health, Epworth Sleepiness Scale (ESS), and Berlin questionnaires were completed, and a physical exam focusing on modified Friedman (MF) grade, body mass index (BMI), and neck circumference (NC) was performed prior to polysomnography. OSA was defined by a respiratory disturbance index ≥15. Each variable was dichotomized, and cutoff values were determined for the NAMES tool in a pilot group of 150 subjects. The NAMES score was calculated from NC, MF, comorbidities, ESS, and loud snoring values. The performances of the NAMES, Berlin questionnaire, and ESS screening tests in predicting OSA were then compared in a validation group of 509 subjects.ResultsIn the pilot population, the cutoff value for the composite NAMES tool was calculated at ≥3 points. In the validation group, NAMES demonstrated similar test characteristics to the Berlin questionnaire, and sensitivity was better than that seen with the Epworth scale. The addition of BMI and gender to the tool improved screening characteristics.ConclusionsThe NAMES assessment is an effective, inexpensive screening strategy for moderate to severe OSA.

Body Mass Index, Gender, and Ethnic Variations Alter the Clinical Implications of the Epworth Sleepiness Scale in Patients with Suspected Obstructive Sleep Apnea§

Introduction: The Epworth Sleepiness Scale (ESS) is often used in the evaluation of obstructive sleep apnea (OSA), though questions remain about the influence gender, ethnicity, and body morphometry have in the responses to this questionnaire. The aim of this study was to examine differences in ESS scores between various demographic groups of patients referred for polysomnography, and the relationship of these score to sleep-disordered breathing Methods: Nineteen hundred consecutive patients referred for polysomnographic diagnosis of OSA completed questionnaires, including demographic data and ESS. OSA was determined based on a respiratory disturbance index (RDI) ≥15 by polysomnography. Results: In this high risk population for OSA, the ESS was 10.7 ± 5.6. The highest ESS scores were seen in obese males; non-obese females and non-obese Caucasian males scored the lowest. ESS was weakly correlated with RDI (r = 0.17, P < 0.0001). The sensitivity of ESS for the diagnosis of OSA was 54% and the specificity was 57%. The positive (PPV) and negative (NPV) predictive values were 64% and 47%, respectively. In obese subjects, the sensitivity and specificity were 55% and 53%, compared with 47% and 63% in non-obese subjects. In obese, Hispanic males, the sensitivity, specificity, and PPV were 59%, 54%, and 84%, respectively. In non-obese, Caucasian females, the sensitivity, specificity, and NPV were 43%, 59%, and 72%. Conclusions: The ESS appears to be affected by many factors, including gender, ethnicity, and body morphometry. The ability of the ESS to predict OSA is modest, despite a significant correlation with the severity of OSA. The test characteristics improve significantly when applied to select populations, especially those at risk for OSA.

Influence of Hispanic ethnicity in prevalence of diabetes mellitus in sleep apnea and relationship to sleep phase.

Abstract Introduction: Recent studies have shown a strong association between insulin resistance, diabetes mellitus, and obstructive sleep apnea (OSA). This association has not been previously reported in the Hispanic population. The objective of this study was to study the prevalence of diabetes in a cohort of Hispanic patients with OSA in comparison with a white cohort. Method: We performed a retrospective chart review of 103 Hispanic patients and 69 white patients with OSA. All patients had undergone full-night baseline polysomnography. We excluded charts of patients who underwent split-night studies and those who did not have rapid eye movement (REM) sleep. Results: Both groups were well matched in terms of age, gender distribution, and body mass index. The prevalence of self-reported diabetes in Hispanic patients with OSA was 42.71% compared with 24.28% of whites (P = 0.005). A REM apnea hypopnea index (AHI) of > 20 was significantly associated with an increased prevalence of diabetes in the Hispanic population; this association was not seen in the white population. Conclusion: There was a very high prevalence of diabetes in an unselected cohort of Hispanic patients with OSA compared with white patients.

Self-reported sleep bruxism and nocturnal gastroesophageal reflux disease in patients with obstructive sleep apnea: relationship to gender and ethnicity.

Study Objectives : Nocturnal bruxism is associated with gastroesophageal reflux disease (GERD), and GERD is strongly associated with obstructive sleep apnea (OSA). Gender and ethnic differences in the prevalence and clinical presentation of these often overlapping sleep disorders have not been well documented. Our aim was to examine the associations between, and the symptoms associated with, nocturnal GERD and sleep bruxism in patients with OSA, and to examine the influence of gender and ethnicity. Methods : A retrospective chart review was performed of patients diagnosed with OSA at an academic sleep center. The patients completed a sleep questionnaire prior to undergoing polysomnography. Patients with confirmed OSA were evaluated based on gender and ethnicity. Associations were determined between sleep bruxism and nocturnal GERD, and daytime sleepiness, insomnia, restless legs symptoms, and markers of OSA severity in each group. Results : In these patients with OSA, the prevalence of nocturnal GERD (35%) and sleep bruxism (26%) were higher than the general population. Sleep bruxism was more common in Caucasians than in African Americans or Hispanics; there was no gender difference. Nocturnal GERD was similar among all gender and ethnic groups. Bruxism was associated with nocturnal GERD in females, restless legs symptoms in all subjects and in males, sleepiness in African Americans, and insomnia in Hispanics. Nocturnal GERD was associated with sleepiness in males and African Americans, insomnia in females, and restless legs symptoms in females and in Caucasians. Conclusion : Patients with OSA commonly have comorbid sleep bruxism and nocturnal GERD, which may require separate treatment. Providers should be aware of differences in clinical presentation among different ethnic and gender groups.