In the September 16th edition of the European Respiratory Journal, there was a study done to assess the benefits of early CPAP treatment on funtional outcome, quality of life, and rates of new cardiovascular events and mortality in patients who suffered their first stroke.
In this study, 325 patients were randomized to CPAP treatment or a control group that did not receive CPAP. 90.5% of the CPAP group had improvements in neurological assessments in one month, which was significantly greater than the 56.3% that showed improvement in the control group. Beyond one month though, results between the two groups did not differ significantly.
Cardiovascular mortality rates did not differ significantly between the two groups. However, the average time from the stroke to the first cardiovascular event was significantly longer in the CPAP group (15 months) than in controls (8 months). This implies that CPAP might help delay the onset of new cardiovascular events in a patient population already at high risk for cardiovascular disease.
Monday, October 25, 2010
Wednesday, October 20, 2010
Sleeping Pills and Death Risk
In the September issue of the Canadian Journal of Psychiatry, a study was performed to assess the mortality risk associated with sleeping pills and anti-anxiety medications. The study involved over 14,000 people aged 18 to 102 who participated in the National Population Health Survey in Canada between 1994 and 2007. Every two years, participants were asked if they used sleeping pills or anti-anxiety medications in the past month.
The overall mortality rate for the entire population was 11.55%. In respondents who took sleeping pills or anti-anxiety pills, the rate was 15.56%. In respondents who said they did not take sleeping pills or anti-anxiety medications, the mortality rate was 10.52%.
After controlling for other factors like alcohol and tobacco use, physical health, physical activity level, and the presence of depression, the mortality rate was still slightly higher in those participants who reported they took sleeping pills or anti-anxiety medications.
The study authors proposed different explanations. Benzodiazepines like Valium could impair reaction time, coordination, alertness, and memory, which then could lead to falls and other accidents. Benzodiazepines could also depress the respiratory system, which could aggravate sleep-related breathing disorders.
Limitations of the study include the fact that medication use was assessed using only two questions. There was no control for the presence of anxiety disorders, whereas the study did control for depression. Also, self-reported data like this survey can introduce a number of biases.
The authors recommend that physicians consider alternative, non-pharmacological treatment of insomnia and anxiety, like cognitive-behavioral therapy, a form of psychotherapy.
The overall mortality rate for the entire population was 11.55%. In respondents who took sleeping pills or anti-anxiety pills, the rate was 15.56%. In respondents who said they did not take sleeping pills or anti-anxiety medications, the mortality rate was 10.52%.
After controlling for other factors like alcohol and tobacco use, physical health, physical activity level, and the presence of depression, the mortality rate was still slightly higher in those participants who reported they took sleeping pills or anti-anxiety medications.
The study authors proposed different explanations. Benzodiazepines like Valium could impair reaction time, coordination, alertness, and memory, which then could lead to falls and other accidents. Benzodiazepines could also depress the respiratory system, which could aggravate sleep-related breathing disorders.
Limitations of the study include the fact that medication use was assessed using only two questions. There was no control for the presence of anxiety disorders, whereas the study did control for depression. Also, self-reported data like this survey can introduce a number of biases.
The authors recommend that physicians consider alternative, non-pharmacological treatment of insomnia and anxiety, like cognitive-behavioral therapy, a form of psychotherapy.
Saturday, October 9, 2010
Obstructive Sleep Apnea and Coronary Artery Disease
In 2005, a study was undertaken to to address the impact of continuous positive airway pressure (CPAP) on patients who had undergone revascularization for coronary artery disease (CAD) and who had documented obstructive sleep apnea (OSA). The study is still ongoing, and researchers have found that the prevalence of OSA is 64% in the CAD population. Hypertension, or high blood pressure, is 58% and obesity is 28% prevalent in CAD.
Patients with CAD and OSA were older, more obese, more often male gender, and had higher incidence of hypertension, diabetes, and atrial fibrillation than those patients with CAD but not OSA.
Interestingly, the risk of CAD was the same in patients with OSA, regardless of their level of sleepiness. And the only difference in the comorbidities of sleepy versus non-sleepy OSA patients was obesity, which was more common in the sleepy OSA patients.
The researchers also studied CPAP compliance. At one year of follow-up, 70% of sleepy OSA patients with CAD were still using their CPAP compared to 60% of non-sleepy OSA patients. This makes sense, as more symptomatic OSA patients are more likely to keep using their CPAP.
The study will conclude in 2012 and the researchers are hoping to prove that treatment of OSA with CPAP will offer patients a non-pharmacologic intervention to reduce the risk of cardiovascular disease.
Patients with CAD and OSA were older, more obese, more often male gender, and had higher incidence of hypertension, diabetes, and atrial fibrillation than those patients with CAD but not OSA.
Interestingly, the risk of CAD was the same in patients with OSA, regardless of their level of sleepiness. And the only difference in the comorbidities of sleepy versus non-sleepy OSA patients was obesity, which was more common in the sleepy OSA patients.
The researchers also studied CPAP compliance. At one year of follow-up, 70% of sleepy OSA patients with CAD were still using their CPAP compared to 60% of non-sleepy OSA patients. This makes sense, as more symptomatic OSA patients are more likely to keep using their CPAP.
The study will conclude in 2012 and the researchers are hoping to prove that treatment of OSA with CPAP will offer patients a non-pharmacologic intervention to reduce the risk of cardiovascular disease.
Monday, October 4, 2010
Older Women and Sleep Apnea Symptoms
There is a summary from Reuters of an article in the September 3rd online paper in the European Respiratory Journal Express. The study authors examined 379 women and 262 men with obstructive sleep apnea (OSA) ages 65 to 70 years old. Specifically, it looked at the different symptoms of OSA in older men versus women.
In this study, more men had severe OSA than women. Men also had a greater body mass index. The women were less likely to report snoring, apnea, or sleepiness, and more likely to be anxious and depressed, and be taking antidepressants and anti-anxiety medications.
This goes along with my clinical experience. Women (not just older women) report less snoring and apneas than men. It could be because they don't snore as much or as loud. Also, their husbands are sometimes less in tune to their wives sleep problems. Since patients rely on bed partners to note snoring or apneas, some women might never realize they are doing that in their sleep. All they know is that they might not sleep well or feel tired or sleepy in the daytime.
Finally, the study authors said older women with OSA were a greater hypertensive (high blood pressure) risk than men, and therefore may have greater cardiovascular mortality and morbidity. This would emphasize the need for early diagnosis to prevent cardiovascular risk. This is true to a point. When a patient reaches a certain age, treating OSA just to prevent cardiovascular disease becomes a "numbers" game. In other words, treating asymptomatic OSA in an 85 year old (male or female) is less likely to prolong life than in a 55 year old, since the 85 year old has already lived longer than the average US lifespan. However, often I suggest treatment in the older patients to improve quality of life, even in those who do not endorse overwhelming symptoms.
In this study, more men had severe OSA than women. Men also had a greater body mass index. The women were less likely to report snoring, apnea, or sleepiness, and more likely to be anxious and depressed, and be taking antidepressants and anti-anxiety medications.
This goes along with my clinical experience. Women (not just older women) report less snoring and apneas than men. It could be because they don't snore as much or as loud. Also, their husbands are sometimes less in tune to their wives sleep problems. Since patients rely on bed partners to note snoring or apneas, some women might never realize they are doing that in their sleep. All they know is that they might not sleep well or feel tired or sleepy in the daytime.
Finally, the study authors said older women with OSA were a greater hypertensive (high blood pressure) risk than men, and therefore may have greater cardiovascular mortality and morbidity. This would emphasize the need for early diagnosis to prevent cardiovascular risk. This is true to a point. When a patient reaches a certain age, treating OSA just to prevent cardiovascular disease becomes a "numbers" game. In other words, treating asymptomatic OSA in an 85 year old (male or female) is less likely to prolong life than in a 55 year old, since the 85 year old has already lived longer than the average US lifespan. However, often I suggest treatment in the older patients to improve quality of life, even in those who do not endorse overwhelming symptoms.
Monday, September 27, 2010
Sleep Duration and Adolescents' Fat and Carb Intake
Another article in the September edition of the Journal Sleep is about how short sleep durations can change the dietary habits of adolescents. The authors begin by pointing out the lack of data quantifying sleep duration and caloric intake. There is an association between sleep loss and obesity, especially in adults. The question is if it's due to increased caloric intake, decreased physical activity, or the same diet, but just altered metabolism.
The researchers measured sleep times in older adolescents with a watch-like device called actigraphy, which can measure sleep at home. They did this during the weekdays only, as weekend sleep times were too variable. They asked the adolescents to recall what food they had eaten, the portions, the percent of fat and carbohydrate, and snacking. They defined short sleepers as getting less than 8 hours of sleep, which is one hour less than the recommended 9 hours per night for adolescents.
The results showed that the average sleep time was 7.55 +/- 1.14 hours and 34% slept at least 8 hours per night. The median caloric intake was 1917 calories, 51% carbs, and 35% fat. If an adolescent slept <8 hours per night, they tended to be obese rather than non-obese. Also, if the adolescent slept <8 hours per night, they had a 2.7% increase in fat consumption and a 3.7% decrease in carbohydrate consumption than those that slept >8 hours.
Those that slept <8 hours / night had a 2.1 fold increase in the odds of eating a high-calorie snack. For each 1 hour increase in sleep duration, the odds of a high-calorie snack decreased by 21%. This was most prominent in girls.
The authors acknowledge the small differences in fat and carb intake, but point out that small increases tend to accumulate and could increase obesity rate.
As I've said in another post, childhood obesity is not caused by short sleep duration. In my opinion, people who sleep less and are obese have extra weight because they have more wake time to eat. Obestity is caused by increased consumption of high-calorie foods rich in salt, sugar, and fat. The food tastes good, so kids eat it, and eat lots of it. They also don't exercise much, as our society is so sendentary. And thinking that if you get an extra hour of sleep, you can magically shed extra weight without serious dietary change is unrealistic.
The researchers measured sleep times in older adolescents with a watch-like device called actigraphy, which can measure sleep at home. They did this during the weekdays only, as weekend sleep times were too variable. They asked the adolescents to recall what food they had eaten, the portions, the percent of fat and carbohydrate, and snacking. They defined short sleepers as getting less than 8 hours of sleep, which is one hour less than the recommended 9 hours per night for adolescents.
The results showed that the average sleep time was 7.55 +/- 1.14 hours and 34% slept at least 8 hours per night. The median caloric intake was 1917 calories, 51% carbs, and 35% fat. If an adolescent slept <8 hours per night, they tended to be obese rather than non-obese. Also, if the adolescent slept <8 hours per night, they had a 2.7% increase in fat consumption and a 3.7% decrease in carbohydrate consumption than those that slept >8 hours.
Those that slept <8 hours / night had a 2.1 fold increase in the odds of eating a high-calorie snack. For each 1 hour increase in sleep duration, the odds of a high-calorie snack decreased by 21%. This was most prominent in girls.
The authors acknowledge the small differences in fat and carb intake, but point out that small increases tend to accumulate and could increase obesity rate.
As I've said in another post, childhood obesity is not caused by short sleep duration. In my opinion, people who sleep less and are obese have extra weight because they have more wake time to eat. Obestity is caused by increased consumption of high-calorie foods rich in salt, sugar, and fat. The food tastes good, so kids eat it, and eat lots of it. They also don't exercise much, as our society is so sendentary. And thinking that if you get an extra hour of sleep, you can magically shed extra weight without serious dietary change is unrealistic.
Friday, September 17, 2010
Insomnia, Sleep Duration, and Mortality
In the September edition of the Sleep Journal, there is an article about the association of insomnia, sleep duration, and insomnia. The authors followed adult men and women to assess death rates. The study participants were assessed with a comprehensive sleep history and physical exam and one night in the sleep laboratory. Insomnia was defined subjectively as an insomnia complaint that lasted for one year. Sleep duration was defined as short if it lasted less than 6 hours per patient's report.
The results showed that in men, the mortality rate was increased for insomniacs with short sleep duration and this was independent of age, race, obesity, alcohol consumption, smoking, obstructive sleep apnea, or depression. The effect was not mitigated by the presence of high blood pressure or diabetes.
There was no increased mortality in women, whether or not they were short sleepers or had insomnia. Also, the association with sleep duration was only for the subjective report, and not based on the duration of sleep measured objectively in the sleep lab.
This study purports to be the first one to link insomnia with mortality. However, the average follow up was 14 years in the men, meaning their sleep study was done at a time when only airflow was routinely monitored. This means that nasal pressure transducers were not used, and therefore sleep apnea could have been present in these men. Sleep apnea is more prevalent in men which could explain why the mortality rate was increased for men and not women.
I'll concede that some patients with insomnia can have a revved up nervous system, referred to as hyperarousal. This, theoretically, could increase cardiovascular disease. But the results of this study do not prove that insomnia by itself increases mortality. Objective monitoring of sleep duration at home over extended periods of time will help answer this question more completely.
The results showed that in men, the mortality rate was increased for insomniacs with short sleep duration and this was independent of age, race, obesity, alcohol consumption, smoking, obstructive sleep apnea, or depression. The effect was not mitigated by the presence of high blood pressure or diabetes.
There was no increased mortality in women, whether or not they were short sleepers or had insomnia. Also, the association with sleep duration was only for the subjective report, and not based on the duration of sleep measured objectively in the sleep lab.
This study purports to be the first one to link insomnia with mortality. However, the average follow up was 14 years in the men, meaning their sleep study was done at a time when only airflow was routinely monitored. This means that nasal pressure transducers were not used, and therefore sleep apnea could have been present in these men. Sleep apnea is more prevalent in men which could explain why the mortality rate was increased for men and not women.
I'll concede that some patients with insomnia can have a revved up nervous system, referred to as hyperarousal. This, theoretically, could increase cardiovascular disease. But the results of this study do not prove that insomnia by itself increases mortality. Objective monitoring of sleep duration at home over extended periods of time will help answer this question more completely.
Tuesday, September 14, 2010
Zeo and Insomnia
I've had a few patients with insomnia try the Zeo. I've even tried it myself. For those unfamiliar, the Zeo is an EEG monitor worn around the head like a headband while trying to sleep. The device will analyze EEG patterns and display your sleep stages for you to review.
I found the headband comfortable enough and the report interesting. I can see where the Zeo could be helpful in some patients. For example, I've had some tell me how their sleep stages changed in response to medication adjustments I made. Some slept deeper or had less dream sleep. I could also see the Zeo help people understand that they might be sleeping more or better than they think they are, as all of us have an imperfect perception of our sleep duration.
The Zeo could also cause more focus on getting the "gold standard" eight hours of sleep per night. I could see some insomniacs becoming more anxious because the Zeo only confirms that they are not sleeping as well or as long as they think they should.
I could see the Zeo being an important tool for diagnosing other sleep disorders in the home as well, especially sleep apnea. A Zeo along with a portable device to measure breathing would be helpful. The entire area of ambulatory monitoring is very exciting to me, as it opens up the possibility of measuring sleep over multiple nights in a patients home environment.
I found the headband comfortable enough and the report interesting. I can see where the Zeo could be helpful in some patients. For example, I've had some tell me how their sleep stages changed in response to medication adjustments I made. Some slept deeper or had less dream sleep. I could also see the Zeo help people understand that they might be sleeping more or better than they think they are, as all of us have an imperfect perception of our sleep duration.
The Zeo could also cause more focus on getting the "gold standard" eight hours of sleep per night. I could see some insomniacs becoming more anxious because the Zeo only confirms that they are not sleeping as well or as long as they think they should.
I could see the Zeo being an important tool for diagnosing other sleep disorders in the home as well, especially sleep apnea. A Zeo along with a portable device to measure breathing would be helpful. The entire area of ambulatory monitoring is very exciting to me, as it opens up the possibility of measuring sleep over multiple nights in a patients home environment.
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