is a comparatively new medication, it has not yet been incorpo- rated into AASM guidelines for the treatment of ES associated with treated OSA. Stimulants, such as amphetamines, reverse the daytime somnolence seen in some patients on CPAP therapy; however, these agents carry a potential risk for abuse and cardiovascular sequelae and further evidence is required before they can be recommended in this indication. 33,36
Abstract: Excessivesleepiness (ES) is a major but underestimated public health concern associated with significant impairments in alertness/wakefulness and significant morbidity. The term ES has been used in the sleep medicine literature for years, but due to its nonspecific symptoms (ie tiredness or fatigue), it frequently goes unrecognized or is misdiagnosed in primary care. In some cases ES arises due to poor sleep habits or self-imposed sleep deprivation; however, ES is also a key component of a number of sleep/wake disorders and multiple medical and psychiatric disorders. Identification and treatment of ES is critical to improve the quality of life and well-being of patients and for the safety of the wider community. The inability of patients to recognize the nature, extent, and symptomatic profile of sleep/wake disorders requires vigilance on the part of healthcare professionals. Interventions to address ES and its associated impairments, treatment of the underlying sleep/wake disorder, and follow-up are a priority given the potential for serious consequences if left untreated. Wakefulness-promoting agents are available that treat ES associated with sleep/wake disorders. This review examines current approaches for managing this debilitating and potentially life-threatening condition, focusing on the place of armodafinil as a wakefulness-promoting agent.
Abstract: Jet lag syndrome (JLS) is a clinical syndrome of disrupted nocturnal sleep and daytime neurocognitive impairment which occurs in the context of rapid transmeridian travel. Many strategies for treatment of JLS exist, and include hypnotics to enhance nocturnal sleep, chronotherapeutic approaches (eg, light therapy, melatonin, or gradual schedule shifting), and alerting agents to counter daytime sleepiness. Safety concerns have prompted renewed inter- est in managing JLS-associated excessive daytime sleepiness (JLSAEDS). Off-label use of the newer alerting agents modafinil and armodafinil is increasing for this indication, often at the specific request of patients. In order to better evaluate the potential risks and benefits of these medications for the management of JLSAEDS, clinicians must be aware of what is known – and still not known. In this article, the pharmacology and pharmacokinetics of modafinil and armodafinil are reviewed, along with evidence for their efficacy in treating sleepiness associated with narcolepsy, obstructive sleep apnea and shift work sleep disorder. Clinical trial data for use of alerting agents in the management of JLSAEDS are limited to one three-day trial involving armodafinil, dosed in the morning to treat JLSAEDS in the setting of eastbound transmeridian travel. This study showed improvement in objective measures of daytime sleepiness at doses of 50 and 150 mg per day. However, global impression of clinical severity of symptom scores only improved on day 1 for those patients receiving 150 mg, and were otherwise not superior to placebo. Consideration for the use of modafinil or armodafinil for the treatment of sleepiness associated with JLS involves careful integration of patient-reported goals, a review of medical contraindications, and an awareness of rare adverse events. More research is needed in order to identify those who are most likely to benefit from this intervention and better define the risk-benefit ratio for this indication.
Abstract: The wake-promoting agent modaﬁ nil is approved for the treatment of excessivesleepiness associated with obstructive sleep apnea (OSA), shift work disorder (SWD), and narcolepsy. In OSA, modaﬁ nil is recommended for use as an adjunct to standard therapies that treat the underlying airway obstruction. This article reviews the literature on modaﬁ nil (pharmacology, pharmacokinetics, efﬁ cacy, tolerability, and abuse potential), with emphasis on use of modaﬁ nil in the treatment of excessivesleepiness in patients with OSA, SWD, and narco- lepsy. In large-scale, double-blind, placebo-controlled studies, modaﬁ nil improved objectively determined sleep latency, improved overall clinical condition related to severity of sleepiness, and reduced patient-reported sleepiness. Improvements in wakefulness were accompanied by improvements in behavioral alertness, functional status, and health-related quality of life. In patients with SWD, diary data showed modaﬁ nil reduced the maximum level of sleepiness during night shift work, level of sleepiness during the commute home, and incidence of acci- dents or near-accidents during the commute home when compared with placebo. Modaﬁ nil was well tolerated, without adversely affecting cardiovascular parameters or scheduled sleep. These ﬁ ndings and those of extension studies which reported improvements were maintained suggest modaﬁ nil has a beneﬁ cial effect on daily life and well-being in patients with excessivesleepiness associated with OSA, SWD, or narcolepsy.
IMPLICATIONS FOR CLINICAL PRACTICE Excessivesleepiness is a significant problem in adolescents and young adults. In most cases, it re- sults from insufficient sleep caused by insufficient time in bed and is associated with intrinsic changes in the sleep/wake cycle as well as extrinsic pressures to go to bed later and get up earlier. At a minimum, clinicians evaluating individuals in this age range need to ask questions routinely about sleep patterns and how much sleep an individual is receiving as well as whether there are any sleep-related symp- toms. Specific tools such as the “BEARS” Pediatric Sleep History (Table 1) have been used in younger children and adolescents 150 and can serve as a tem-
Abstract: Excessive daytime sleepiness (EDS) can be caused by insuf ﬁ cient sleep but is also a manifestation of medical or sleep disorders and a side effect of medications. It impacts quality of life and creates safety concerns in the home, at work, and on the roads. Screening questionnaires can be used to estimate EDS, but further evaluation is necessary. EDS is a common symptom of both narcolepsy and obstructive sleep apnea (OSA). Polysomnography and multiple sleep latency testing are used to diagnose these disorders. However, isolating the primary etiology of EDS can be challenging and may be multifactorial. Untreated OSA can show polysomnographic ﬁ ndings that are similar to narcolepsy. The effects of sleep deprivation and certain medications can also affect the polysomnographic results. These challenges can lead to misdiagnosis. In addition, narcolepsy and OSA can occur as comorbid disorders. If EDS persists despite adequate treatment for either disorder, a comorbid diag- nosis should be sought. Thus, despite advances in clinical practice, appropriate management of these patients can be challenging. This review is focused on EDS due to OSA and narcolepsy and addresses some of the challenges with managing this patient population. Keywords: EDS, excessive daytime sleepiness, narcolepsy, OSA, obstructive sleep apnea
A repeat overnight PSG was completed at five years three months of age due to ongoing concerns of EDS and cataplectic episodes. The goals for treatment were to optimize school performance and ensure our pa- tient’s safety. At that time, episodes of cataplexy were still occurring, mainly in the mornings upon awaken- ing. The results of the second PSG study (Table 1) were abnormal and suggestive of narcolepsy. Spikes were noted on electroencephalography without any seizure activity and a shortened REM sleep latency was observed. The overall degree of SDB was improved compared to the previous measurement. Abnormal respiratory events were limited to one obstructive apnea and two obstructive hypopneas with an AHI of 0.4 events per hour. The average EtCO 2 was
Results: Our results showed that 39.5% of participants were found to have a high risk of sleep apnea and 9.9% of the participants were found to have abnormal daytime sleepiness. The risk of developing OSA was associated with a higher body mass index (BMI) (P=0.02), and depression severity (patient health questionnaire 9 score) (P=0.01). Increasing severity of depressive symptoms was associated with a higher risk of sleep apnea (P=0.01). BMI (odds ratio [OR] =5.97, 95% confidence interval [CI] 1.89–18.82) and depression severity (OR =4.04, 95% CI 1.80–9.07) were also found to be predictors of OSA. The psychiatric diagnoses of the participants were not found to have a significant association with the risk of sleep apnea. Conclusion: The risk of OSA is increased among hospitalized psychiatric patients, and this condition can have detrimental effects on psychiatric patients. OSA appears to be under- recognized in this population, psychiatrists should screen for OSA in hospitalized psychiatric patients and refer them for diagnostic testing or treatment when indicated.
Narcolepsy is a chronic neurological disorder specifying the abnormal sleep manifestations which mainly impact the quality of life of narcolepsy patients. The exact cause is unclear but found significant evidences that orexin/hypocretin deficiency causes narcolepsy which regulates sleep. Treatment focuses on symptomatic relief throughout medication, education, and behavioral therapy. Stimulants are the first line treatment for the excessive daytime sleepiness. Modafinil, sodium oxybate, amphetamine, methylphenidate, and selegiline are effectual treatments for somnolence associated with narcolepsy. Tricyclic antidepressants and SSRIs are one of the best treatments for cataplexy, sleep paralysis, and hypnagogic hallucinations. Benzodiazepines are the best regimen for disturbed nocturnal sleep.
Thus sleep quality is seen poor in diabetic patients. To improve sleep quality, a clinical pharmacist can help patients to follow good sleep habits. The pharmacist encourages patients to engage in good sleep hygiene to reduce daytime sleepiness and instruct patients that adequate high-quality sleep is important to improve daytime function. Good sleep hygiene includes ensuring adequate sleep duration, developing sleep promoting bedtime rituals, avoiding staying in bed if unable to sleep, and avoiding caffeine if it disturbs the patient’s ability to fall asleep. There are many effective treatments for sleep disorders, and the deleterious health effects of insufficient sleep or a coexisting sleep disorder warrant greater attention. Pharmacist can be instrumental in encouraging adherence to treatment for sleep disorders. Although persons with diabetes are instructed to restrict calories and to increase physical activity, the presence of less than optimal sleep may undermine these important treatment goals. Thus, educating patients with type 2 diabetes about the importance of sleep and regular screening for sleep disorders has the potential for a positive clinical outcome .
The patient has a primary generalized epilepsy with an overlap syndrome between phantom absences and juvenile myoclonic epilepsy (JME). Treatment with levetiracetam did not control her myoclonic jerks or staring spells, and caused mood changes. Levetirac- etam was discontinued and she was started on val- proate after counseling regarding possible side effects. She had a good clinical response and her EEG improved remarkably. We believe that treatment of OSA as well as effective use of appropriate antiepilep- tic drugs was responsible for the significant improve- ment in her sleep and daytime alertness, and disappearance of dream mentations and fainting spells.
these preliminary assumptions and indicates that BMI plays a major role in defining the phenotype of OSA in children. At equivalent levels of OSA severity, the like- lihood of MSL of ⱕ 12.0 minutes was more than sixfold greater for obese children, and a strong association emerged between BMI and sleep propensity (Fig 1). These and other differences in the clinical syndrome of OSA among nonobese and obese children prompted us to propose the existence of 2 types of clinical OSA, which may have implications not only regarding the type and extent of end-organ dysfunction induced by the recur- rent upper airway obstruction during sleep but also re- garding treatment outcomes. 31–34 Of note, there were no
The ESS score was used to measure the clinical impact of EDS. It is defined as a simple and self-administered questionnaire which provides a measurement of the sub- ject’s general level of sleep propensity and likelihood of dozing off in eight different real-life situations. All items are rated on a 4-point Likert scale, 0 = would never doze, 1 = slight chance of dozing, 2 = moderate chance of doz- ing, 3 = high chance of dozing. Scores vary from 0 to 24, with higher scores indicating higher levels of sleepiness . At present, there are no universally adapted cut-off ranges for the ESS, but Drager et al. determined the sen- sitivity and specificity of ESS in predicting OSA (defined as ESS score >10) as 49 % and 80 %, respectively . According to domain experts, we considered a 1-point reduction in ESS score to be clinically significant .
Although our result pointed out that insufficient sleep is one of the most important factors affect EDS in OSAS patients, the management of EDS in the OSAS patients under CPAP treatment is a multifaceted problem includ- ing treatment, social and healthcare related factors, and these need to be discuss comprehensively. Knowledge about facilitators and barriers for adherence to CPAP treat- ment can be used in interventional strategies . This can be increased by intensive patient education. The use of a wake-promoting medication, modafinil, is also ap- proved for OSAS patients who are adherent to CPAP therapy but exhibit a residual EDS . However, the common side effects of modafinil include headache (28%), anxiety (16%), and nervousness (14%). In addition, the possibility that addiction to modafinil may be probable . Before the prescription of stimulants, it is necessary to establish an educational program for OSAS patients under CPAP treatment to enlighten what patients can do for themselves about sleep hygiene.
Performance deficits during neuropsychological tests can be documented with even mild OSA. Health - related quality of life (HRQL) is an important domain for measuring the impact of chronic disease . In patients with OSA excessive daytime sleepiness (EDS), may contribute to the impaired quality of life (QOL) . Apart from serious and life threatening disorders such as hypertension, acute myocardial infarction, cerebrovascular accident and heart failure, OSA causes defects in cognitive functions and mood. Neuropsychological impairment, resulting from OSA, affect daily life activities and the ability to set up regular social life. Although some studies reported that anxiety and depression are more common among OSA patients, and impairing the quality of life is much severe compared to normal population, other studies report no relationship between OSA and QOL, anxiety and depression .
Then, the staff identified the suitable mask and held a session of education and training to CPAP therapy and mask fitting. The duration of this phase was about 30 min. Subjects were allowed to choose to receive CPAP titration at home or in the laboratory. Titration was performed using auto-adjusting CPAP units (S9TM, ResMed Ltd, Bella Vista, Australia) at patients’ home for 3 to 5 nights or in the sleep lab . Throughout the night and the next morning, the staff on duty in the lab dealt with any discomfort related to the CPAP treatment. The pressure selected for CPAP treatment was the pressure at which the participant spent 90% of the time with apnea-hypopnea index (AHI) lower than 10 events/hour . Successful unattended titration of APAP require a minimum of 1 night with at least 6 h of total recording, and at least 5 h with a mean mask leak <0.4 l/s . We considered the home titration acceptable if it was carried out ≥2 nights, its average duration was ≥ 4 h/night and leaks were <24 l/min.
Overall, there has been recognition that psychological and behavioural factors have a significant role in the treatment of insomnia to the extent that there has been increased interest in therapies targeting these factors (Morin, et al., 2006). A systematic review of 37 treatment studies (N = 2246) published between 1998 and 2004 inclusive, revealed that psychological and behaviour therapies produced changes in several parameters (e.g., beliefs about sleep, sleep quality, sleep efficiency, sleep onset latency) of individuals with either primary insomnia or insomnia associated with medical or psychiatric disorders (see Morin, et al., 2006 for detailed analysis of treatment studies). According to Morin et al (2006), five treatments in particular met American Psychological Association (APA) criteria for empirically supported psychological treatments for insomnia: stimulus control therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavioural therapy.
Methods: Data for this study were from a 2012 – 13 baseline assessment of the First Nations Lung Health Project, in collaboration between two Cree First Nation reserve communities in Saskatchewan and researchers at the University of Saskatchewan. Community research assistants conducted the assessments in two stages. In the first stage, brochures describing the purpose and nature of the project were distributed on a house by house basis. In the second stage, all individuals age 17 years and older not attending school in the participating communities were invited to the local health care center to participate in interviewer-administered questionnaires and clinical assessments. Excessive daytime sleepiness was defined as Epworth Sleepiness Scale score > 10.
either case, this must be done in a culturally and linguistically appropriate manner when targeting minority communities. Second, overall management of hypertension should include newly identified comorbid conditions including sleep-related problems and not solely the traditional conditions like diabe- tes and chronic kidney disease. Third, behavioral interven- tions that seek to address adherence status should include adherence to both prescribed sleep and hypertension regi- mens. Finally, studies may also wish to look at mechanistic factors that may be common to both daytime sleepiness and adherence, such as stress, especially in low-income com- munities such as the ones sampled in this study. 37
Excessive daytime sleepiness (EDS) is a common clinical problem. It is one of the main consequences of sleep disorders and it is associated with a reduction of the quality of life, road accidents and workplace accidents [1, 2]. EDS is an inability to maintain vigilance and alertness during major period of the day when subject is expected to be awake, with sleep occurring unintentionally or at inappropriate times and this almost daily . Its prevalence is estimated between 10 and 20% in the general population [4–12] and reaches 68% in some groups of patients . The independent association between EDS and hypertension is found in several studies including patients with sleep apnea syndrome (SAS) [13–16]. Hypertension is a common condition in the general population and is one of the major risk factors for cardiovascular mortality and morbidity . Studies of the relationship between EDS and hypertension in the general population regardless of association with SAS are scarce. In a prospective cohort study carried out in a relatively healthy adult population, Goldstein et al. found a high risk of developing hypertension in subjects with EDS . Otherwise, in a recent prospective cohort study in Brazil, Drager et al. did not find any association between hypertension and EDS . Moreover, in a group of subjects recruited from a sleep laboratory in China, normotensive subjects had a more severe SDE than hypertensive subjects with OSA . The factors associated with EDS in hypertensive subjects are obesity, type 2 diabetes and uncontrolled hypertension . In this light, we carried out this study having as objective to investigate the association between the EDS and hypertension, and to determine the factors associated with the EDS in the subjects having hypertension in the general adult population of Cameroon.