New Surgical Treatment for Obstructive Sleep Apnea

The most effective treatment for obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP), which is pressurized air delivered with a mask worn with all sleep. Not every patient tolerates CPAP and numerous surgical alternatives to CPAP have been developed. No surgical treatment works as well as CPAP.

One type of surgery is called genioglossal advancement, which is a fancy way of saying that the base of the tongue is pulled closer to the lower jaw. By doing this, the space behind the tongue is enlarged, meaning that the amount of OSA could be significantly reduced.

Siesta Medical has just received FDA approval for their EncoreTM surgical treatment for OSA - see the picture below. From their website..."The EncoreTM System is used in a minimally invasive surgical procedure where the tongue is suspended forward with the intent of preventing collapse of the airway during sleep. The procedure is performed under local or general anesthesia by Ear, Nose and Throat Specialists, also known as Otolaryngologists. During the procedure, an intra-tissue suture passer is used to place a suspension loop in the tongue which is then attached to the base of the chin with a knotless bone anchor. The EncoreTM System greatly simplifies tongue suspension and provides the surgeon excellent control of positioning and tensioning of the suspension loop."

Insomnia and Depressed Adolescents

Approximately 5 to 6% of adolescents develop depression, and remission rates for treatment are low. Studies have shown that about 3/4 of depressed adolescents have insomnia. Insomnia is known to produce poor outcomes in depressed adults, but studies have not been done on insomnia's effect on depressed adolescents.

Research was presented at the 24th Congress of the European College of Neurospsychopharmacology about adolescents with depression and insomnia. For the study, data was examined from the Treatment for Adolescents with Depression Study. In that study, 439 adolescents (age 12 to 17 years old) were randomized to 12 weeks of treatment with Prozac, psychotherapy, Prozac plus psychotherapy, or placebo.

The results showed that 64% of the participants had insomnia and that those with insomnia had more severe depression at the beginning of the study. Depressed adolescents with insomnia were more likely to report suicidal thoughts and their depressive episodes were more prolonged.

At 6 weeks of treatment, those with insomnia responded less than those without insomnia, but at 12 weeks, the response rate did not differ significantly between the 2 groups. The study authors concluded that insomnia could slow adolescents' response to depression treatment, and that adding insomnia treatments early in the course of depression treatment could speed up recovery.

Night Owls and Nightmares

I came across an abstract in the August 25th online edition of the journal Sleep and Biological Rhythms about the relationship between nightmares and sleep time preference. Researchers administered questionnaires to 264 medical students, ages 17 to 26 years old. They assessed if the students were morning (morning lark) or evening (night owl) types, the quality of their sleep, and how frequently they experience nightmares.

The results showed that men were more likely than women to be night owls. Night owls were more likely to report poor sleep quality, daytime sleepiness, and distrubing nightmares than morning larks. The authors point out that night owls are more likely to have substance abusers, bulimia, other sleep disorders, ADHD, suicidality, and mood disorders. Also, night owls could have increased stress because of the difficulty holding down a job or attend classess if you are not able to wake up until the late morning. These factors could explain why night owls are more prone to nightmares.

Sleep Disturbance, Blue Light Transmission, and Yellow Lenses

Our biological clocks control important daily activities like sleeping. Sleep scientists have known for years that morning light exposure can regulate our biological clock to the 24 hour cycle. In particular, blue light appears to be the strongest clock stimulator. It tells our brains it's time to be awake by stimulating cells in the back of the eye, which then tell the sleep-wake centers deep in our brains.

As we age, the lenses in our eyes turn more yellow-brown in color - this color change can filter out blue light. This means that less blue light gets in to the back of the eye, so that the brain is not told as strongly when to be awake. This could result in sleep disturbances as older people's body clocks do not follow the typical 24 hour cycle. And, sleep quality has been shown to improve after cataract surgery, which is a replacement of the lens.

In the Sleep Journal, a study was done to examine the relationship between aging lenses in the eye and sleep disturbances. Researchers took 970 people ages 30 to 60 years old and asked them if they often suffer from insomnia or if they had bought prescription medications for sleeping disorders within the past year. A positive response to either inquiry was counted as a "sleep disturbance." The researchers also measured the amount of blue light transmitted through their lenses.

The results showed that 24.4% of the participants had a sleep disturbance. Also, the less blue light transmitted, the higher the risk of a sleep disturbance, even after correcting for age, sex, diabetes, smoking, and risk of ischemic heart disease. The study authors recommend that prescribing physicians reconsider sleep aids in patients that have undergone cataract surgery - they might not need them anymore.

Insomnia and US Work Performance

Insomnia symptoms are very common and have been associated with workplace deficits. Kessler et al have published results of their study in the Sleep Journal regarding insomnia and its effects on work performance in Americans. The researchers surveyed 7428 employed health plan subscribers by telephone. Insomnia and workplace performance were assessed with validated questionnaires. Comorbid conditions that could decrease workplace performance were also assessed.

The results showed that insomnia occurred in 23.2% of the survey participants. Lost work performance due to insomnia occurred in 20.3% of the sample. About 1/3 of that 20.3% was due to missed days of work with the other 2/3 being low performance at work. These numbers translated to 8 days per year of lost work performance at a cost of $2,280 for each worker with insomnia after controlling for comorbid conditions. At the population level, this means that insomnia is associated with 253 million days of lost work performance at a cost of over $63 billion.

The study authors discussed the relevance of their findings and whether workplace screening and treatment programs for workers with insomnia would be cost-effective from an employer's perspective. The study authors point out that most insomniacs do not seek treatment despite effective treatments like cognitive behavioral therapy. They recommend controlled workplace effectiveness trials to obtain return-on-investment estimates of workplace insomnia interventions.

Valerian and Insomnia in Post-Menopausal Women

About half of post-menopausal women experience sleep disturbances such as insomnia. In the September issue of the journal Menopause is a study about the effect of valerian on sleep quality in post-menopausal women. There were 100 participants ranging in age from 50 to 60 years old. They were given an insomnia questionnaire, but I do not think they were diagnosed by a sleep physician. They did not have sleep studies.

The women were randomly assigned to take either concentrated valerian extract or a placebo twice daily. It's not clear why the participants were given the medications twice daily. Usually, insomnia medications would be given at or near bedtime only. The results showed that the women who took the valerian reported 30% improvement on their scores on the insomnia questionnaire, compared to only 4% improvement in those taking placebo. The women reported no side effects from valerian.

The study authors concluded that valerian improves sleep quality in post-menopausal women experiencing insomnia. Some caution is warranted here. Other studies have not shown such a dramatic effect for valerian. The women taking the valerian might feel sleepy in the daytime due to taking it twice daily. The women taking placebo would not feel sleepier in the daytime. This could introduce bias, as the women taking the valerian might figure out that the are taking the active medicine and expect to sleep better or just think they are sleeping better, because they are getting the real thing. Valerian is not regulated by the FDA, so you really do not know what you are getting when you buy a bottle off the shelf - the pills might not contain any valerian at all!

Also, these women were not diagnosed with insomnia, but did have poor sleep quality. However, the etiology for the insomnia is not known. Being post-menopausal can decrease sleep quality, but so can obstructive sleep apnea (OSA), and the risk of OSA goes up significantly in women after menopause. So instead of reaching for the valerian (or any other sleep aid), discuss your symptoms with your doctor first.

Deep Sleep, High Blood Pressure, and Elderly Men

There is an abstract in the journal Hypertension from August 2011 about the relationship between sleep stages and development of high blood pressure (a.k.a. HTN). There are three stages of sleep - light non-REM sleep, deep sleep, and REM (a.k.a. dream) sleep. Researchers studied 784 men greater than 64 years old who did not have HTN with an in-home sleep study. After a mean follow up of 3.4 years, 243 developed HTN. Analyses of the results demonstrated that developing HTN was associated with low oxygen levels, increased light non-REM sleep, and decreased deep sleep. After adjusting for age, nonwhite race, study site, and body mass index, only deep sleep was associated with developing HTN. The association was not reduced even after accounting for sleep duration, sleep fragmentation, and severity of sleep-disordered breathing (e.g. obstructive sleep apnea).

The researchers concluded that reduced deep sleep may contribute to adverse blood pressure in men. Unfortunately, the percentage of sleep that is deep sleep normally reduces with age in men and women. At the current moment, there is not a reliable way to increase deep sleep percentage without sleep deprivation or using medications.

Female Hormone Therapy and Insomnia Symptoms

In the journal Menopause is a study about the effects of stopping hormone therapy on sleep in women going through menopause. Researchers analyzed data from 1405 women (average age 60 years) who were randomized to either continue their hormone therapy, stop it for one month, or stop it for two months. The women filled out sleep questionnaires at the beginning of the study and three months later.

The results showed that compared to the women who continued therapy, those women who stopped therapy for two months reported 46% more days with trouble falling asleep and sleeping poorly, and 31% more days waking too early. The effect on sleep of the one month therapy stoppage was less pronounced but still statistically significant. The results held up even when potentially confounding factors like alcohol use, body mass index, age, race, and ethnicity were taken into account.

The researchers hypothesized that the women who stopped therapy had insomnia symptoms because of a return of vasomotor symptoms like hot flashes. This could be true and I also think there could be another contributor. Female hormones have been shown to improve muscle tone in the upper airway, which could theoretically reduce obstructive sleep apnea. It could be that stopping the female hormones cause the women to experience more insomnia from a worsening of underlying obstructive sleep apnea.

The take home message is that if you are going to stop female hormone therapy, be prepared for potential worsening of sleep quality. Instead of reaching for a sleep aid, discuss your symptoms with your doctor first.

Insomnia in Cancer Patients

Researchers in Canada assessed 962 patients undergoing cancer surgery for insomnia symptoms and followed them for 18 months. At the time of their surgery, 59% of patients reported insomnia symptoms, with 28% meeting criteria for an insomnia disorder, meaning they took more than 30 minutes to fall asleep at least three times per week. A year and a half later, 36% of study participants reported insomnia symptoms. Insomnia rates were greater in women than men, which reflects what we normally see in the general population.

The etiology of the insomnia was not evaluated in this study, but the findings are important because they bring attention to an important aspect of cancer patients' health. Hopefully, oncologists will include sleep quality in their assessments, and refer those patients with a possible sleep disorder to a sleep center for help.