Dental Clinicians’ Observations of Combination Therapy in PAP-Intolerant Patients

March 9, 2015

Based on the experiences of four highly experienced dental sleep practices, this pilot study sought to determine whether combination therapy, in which a PAP interface and mandibular advancement splint are physically connected, may provide a more acceptable therapeutic modality in obstructive sleep apnea patients who have abandoned conventional PAP therapy.

By Anne E. Sanders, MS, PhD, MS; Martin A. Denbar, DDS, DABDSM; John White, DDS, DABDSM; Ronald S. Prehn, ThM, DDS, DABDSM; Robert R. Rogers III, DMD, DABDSM; Thomas Pardue, BA; Max Schweizer, BS; and Greg K. Essick, DDS, PhD

TAP-PAPComboTherapy

In the PAP/MAS device, the PAP interface (nasal pillows) is connected to, and stabilized in position by, a rod extending from the oral appliance, a mandibular advancement splint. This obviates the need for headgear required when the PAP interface and oral appliance are not connected.

Patients with obstructive sleep apnea (OSA) attribute their poor tolerance of positive airway pressure (PAP) therapy to the presence and fit of headgear and chin straps, claustrophobia, unstable or inadequate fit of mask to facial contours, air leakage, mask-related skin ulceration and headache, aerophagia, and uncomfortably high pressure levels. As a result, only about 50% of patients continue to adhere with therapy after 1 year.

Anecdotally, sleep clinicians claim better tolerance when PAP therapy is used in conjunction with a mandibular advancement splint (MAS), but published evidence is scarce. The MAS stabilizes and advances the mandible, simulating jaw thrust and clearing the upper airway for unobstructed breathing. Improved tolerance of this combination therapy (CT) is attributed to fewer pressure-related complaints. El-Sohl et al showed in 10 patients that CT reduced both the effective continuous PAP and pressure-related complaints shortly after implementation. Consistent with lower effective pressures, Borel et al found that velopharyngeal resistance is lower with CT than with a nasal mask alone. 

In both studies, the MAS and PAP mask were not physically connected.

The PAP interface, however, can be physically connected to and supported by a MAS, eliminating the need for headgear. One early case report6 described a patient whose responses to PAP and to MAS therapy were poor, but who achieved near normal sleep respiration and a lower minimally effective PAP upon stabilization of the mandible in an upward and forward position, as corroborated elsewhere.  By analyzing existing data from four dental sleep practices, we sought to determine whether PAP delivered through an interface connected to a MAS can offer a more accepted therapeutic alternative for OSA patients who have failed conventional PAP therapy. 

Methods

The study employed a retrospective cohort design in which four dental sleep medicine experts in separate US practices retrieved existing data from records for all consecutive patients aged ≥18 years meeting inclusion criteria. The inclusion criteria were: physician diagnosis of OSA and referral to a dentist; having failed conventional PAP therapy; having attempted MAS-PAP within a specified time interval; and being on active recall for therapy evaluation. Clinicians were diplomates of the American Board of Dental Sleep Medicine with collective experience treating more than 14,000 patients with oral appliances for sleep-disordered breathing over a total of 79 years. The Biomedical IRB at the University of North Carolina at Chapel Hill approved the study.

De-identified diagnostic and CPAP titration information from patients’ sleep study reports and clinical records of CT were extracted and recorded on a standardized pretested electronic form.

Investigation was restricted to a single commercially available CT device—the TAP-PAP Chairside (manufactured by Airway Management Inc). In this device, a horizontal rod is secured to the upper component of a MAS, and a nasal pillow/hose assembly is attached using an acrylic material.

Tolerance was defined by clinician report that the patient was continuing to use PAP/MAS, based on periodic recall and ongoing evaluation by the dental sleep expert in the dental office. Acceptability was evaluated by patient report of complaints. Evidence of efficacy was determined in a subset of patients by comparison of follow-up polysomnogram or home sleep study against the diagnostic polysomnogram.

Data were imported into StataCorp LP Stata 13.1 Statistical Software for statistical analysis. Pearson chi-square tested the significance of differences between categorical variables. A paired t-test tested the null hypothesis that apnea-hypopnea index (AHI) values at OSA diagnosis did not differ from those obtained following PAP/MAS.

Results

Among 92 OSA patients aged 25 to 85 years (mean 55 years), the mean polysomnogram-determined diagnostic AHI value was 37.6 (standard deviation (sd): 25.9). Half (n=46) met the diagnostic threshold for severe OSA (AHI ≥30), a quarter (n=23) had moderate OSA (AHI 15–29.9), and the remainder (n=23) had mild OSA (AHI 5–14.9).  

Because the proportion of PAP/MAS tolerant patients did not differ between the practices (P = 0.612), results report pooled data. Overall, 65 patients (70.7%) tolerated PAP/MAS therapy, having used it for 14.0 months on average (sd: 11.1). Although tolerance was higher in patients with severe OSA (76.1%) than mild OSA (69.8%), this difference was not statistically significant (P = 0.421).

Patients expressed substantially fewer complaints to their dentists about PAP/MAS than conventional PAP (Table 1). The most common complaints about conventional PAP related to mask discomfort and leakage, and the perceived ineffectiveness of PAP. Again, mask discomfort and leakage were the most common complaints about PAP/MAS, but these were reported by only a small minority of patients. 

A follow-up polysomnogram or home sleep test was available for 34 of the 65 PAP/MAS tolerant patients while using PAP/MAS. Patients with severe OSA were more likely to have had the follow-up polysomnogram than those with mild OSA (P = 0.023). In these patients, AHI values decreased from an untreated mean of 48.0 (sd: 28.3) events/hour to a treated mean of 3.1 events/hour (sd: 3.8) (P < 0.001), indicating that, on average, PAP/MAS eliminated OSA.

Discussion

In this study of patients who had abandoned conventional PAP, 70.7% were reported using PAP/MAS for 14.0 months, on average, after initiation of treatment. PAP/MAS tolerant patients expressed to their sleep dentists substantially fewer complaints about the CT than conventional PAP. CT reduced the AHI to less than 5, on average, achieving values not dissimilar from those achieved with conventional PAP.

Several explanations may account for better tolerance of CT. Borel et al⁵ found that joint use of PAP with MAS was at least equally effective as nasal PAP alone by increasing airway patency beyond that achieved solely with PAP. Using a phrenic nerve magnetic stimulation paradigm, the investigators showed greater decrease in velopharyngeal resistance with CT. Since resistance values determined this way are related to pressures at which the pharynx collapses, the joint therapies act synergistically to improve velopharyngeal area patency, the area primarily implicated in upper airway collapse.

El-Sohl et al found that the CPAP intolerance was associated with high pressure-related complaints. In agreement with greater pharyngeal patency demonstrated by Borel et al, El-Sohl et al also demonstrated that CT lowered the optimal pressure 29% on average and was well tolerated.

PAP therapy adherence is influenced by the mask interface. Typically, when a nasal mask results in air leakage via the mouth, an oronasal mask is tried. However, the higher pressures required for oronasal masks are associated with greater air leakage, more arousals, more residual respiratory events, dry mouth, and worse adherence than nasal masks. In addition, their manner of attachment tends to push the mandible and tongue backward, increasing the airflow resistance.

A nasal interface used with MAD overcomes the aforementioned problems. The effective pressure is typically lower than with a nasal mask. Rather than pushing the mandible backward, it is stabilized in a neutral or forward position, lowering velopharyngeal resistance and improving upper airway patency. As the mouth is kept closed, air leakage and mouth breathing are minimized.

Because nasal pillows have less facial contact, problems of claustrophobia, air leaks around the eyes, and pressure sores are minimized.  In their randomized cross-over study, Massie and Hart compared nasal pillows to nasal masks using pressures ranging from 5 to 14 cm H₂0. They reported no differences in treatment efficacy, effective CPAP pressure, Epworth sleepiness score, or quality of life measures. The nasal pillows produced fewer adverse effects, less air leakage, less difficulty sleeping and maintaining sleep, and improved sleep quality.

The nasal pillows in our study were supported via a rod extending from the maxillary component of the MAS, obviating need for a chin strap and headgear to support the air interface. This confined facial contact to the external nares and lip vermilion over which the supporting rod extended. Moreover, the rigidity of the connection with the MAS secured the nasal pillows in a stable “locked” relationship with respect to the external nares to minimize air leaks and thus disruptive arousals from sleep. Air leakage is a major deterrent to the use of PAP, hence the substantial reduction in complaints of “air leakage” and “not being able to keep in place” with PAP/MAS may, in part, underlie its success.

PAP/MAS-tolerant patients had remarkably fewer complaints about the CT than conventional PAP. Our expectation that the addition of MAS would cause discomfort in masticatory muscles, TMJ, and teeth, was not met. CT may be successful with a lesser degree of jaw advancement than required for treatment with a MAS alone,¹ thereby minimizing dental side effects.

The use of CT as a first-line therapy, rather than a rescue, may decrease the number of patients who remain untreated from nonadherence to PAP therapy. Compared to conventional PAP, CT appears to offer improved comfort and interface stability, and a reduction in air leakage.

We recognize the many limitations of this pilot study. Data were limited to existing clinical records of community-based dental sleep practices. Because of this, the patients were not matched either within or across the four practices. There was no standardization of the PAP titrations, types of masks employed, or counseling that the patients received on use of conventional PAP or combination therapy. The amount of jaw advancement with PAP/MAS was not standardized within or between practices, which could have affected tolerance of the CT. There was no standardization of the follow-up PSG or home sleep study, and these data were not available for approximately half the CT-tolerant subjects. Data were not available for the nightly duration of PAP/MAS use. Nonetheless, the consistency of the experiences reported across the four unrelated, expert dental sleep practices supports the general conclusion that PAP/MAS can provide an effective treatment for OSA in many otherwise CPAP-intolerant patients and merits formal evaluation in a prospective controlled clinical trial.

In Resistant Hypertension, Sleep Apnea Results in Greater Blood Pressure and Treatment Lowers It.

Published on April 6, 2015

A new meta-analysis published in the Journal of Hypertension suggests that untreated sleep apnea may be a major factor in why medications appear to be less effective in reducing high blood pressure in some people. Further, the study shows that CPAP therapy may be the key to helping those with difficult to treat hypertension get their blood pressure under control.

As many as 10 million people in the United States have “resistant hypertension” which either doesn’t respond to or requires multi-drug therapy. Most people with resistant hypertension also have obstructive sleep apnea (OSA). It’s a deadly combination that exponentially increases the risk of death or disability from a stroke or heart attack, but one that researchers say may have a relatively simple solution.

“Our study indicated that the patients with resistant hypertension and the very highest blood pressure experienced the greatest reduction in blood pressure after using CPAP therapy,” says Ulysses Magalang, MD, the study’s principal investigator and director of the Sleep Disorders Center at The Ohio State University Wexner Medical Center, in a release. “This response suggests that untreated sleep apnea may be why these people haven’t seen improvement in their blood pressure despite the concurrent use of three or four medications.”

Previous studies have shown that CPAP therapy offers patients with hypertension a significant, yet modest two to three point reduction in blood pressure. Magalang and the research team found that when they honed in on the specific results for those with resistant hypertension, the benefits of CPAP use looked quite different.
In their study, patients experienced an average reduction of 7.21 millimeters of mercury (mmHg) in ambulatory systolic blood pressure (SBP), and 4.99mmHg in ambulatory diastolic blood pressure (DBP) from baseline after using CPAP therapy. Ambulatory blood pressure (measured over a 24 hour period) is considered a good predictor of future organ damage and cardiovascular problems.

“We know that small changes in blood pressure translate into big benefits in terms of protecting the heart and reducing stroke risk,” says co-author Christopher Valentine, MD, a nephrologist at Ohio State’s Wexner Medical Center. “These findings suggest that physicians may need to be more aggressive with screening for sleep apnea and ensuring CPAP therapy compliance in patients with resistant hypertension.”

Systematic Analysis of Resistant Hypertension and CPAP Use

Despite the fact that millions of people suffer from resistant hypertension, and that its cardiac comorbidities carry a significant public health burden, studies looking at CPAP use and hypertension historically haven’t focused on this difficult to treat population.

“We have a lot of evidence about the benefits of CPAP in people with hypertension and OSA, but ours is the first analysis to systematically review CPAP use in people with difficult to treat hypertension and apnea,” Valentine says. “The results are clinically relevant because the effects that we found are significantly higher than what’s been previously observed in a more general hypertensive population. CPAP use could offer this subset of patients a new chance to reach a healthier blood pressure goal, or even to reduce their medication burden.”

From an initial scan of 157 articles, the researchers narrowed the data from 6 different studies, looking at pre- and post-CPAP blood pressure measurements from more than 300 patients with resistant hypertension. The duration of CPAP use ranged from 3 weeks to 6 months. In addition to measuring ambulatory blood pressure, investigators also looked at CPAP therapy and its impact on nighttime blood pressure—another predictor of future cardiac events.

While the researchers found significant improvement in ambulatory and nocturnal blood pressure measurements after CPAP use in some of the studies, other cuts of the data showed that CPAP therapy delivered about the same nocturnal blood pressure benefit as observed in previous studies.

“More studies are needed to further define CPAP influence on blood pressure, but overall, we think that the longer the CPAP is used during the night, the greater the impact,” Magalan says.

The authors also acknowledge other limitations of their analysis, including small sample size, and potentially confounding factors such as the concomitant use of the antihypertensive medications, obesity, and other life-style factors such as the use of alcohol and smoking.

Sleep Apnea, High Blood Pressure: Shared Genetic Origins?

Magalang and Valentine say their findings also support the idea that resistant hypertension and OSA represent an “extreme phenotype” of those who have OSA, but never develop hypertension. A phenotype describes how an individual’s characteristics are influenced by the interaction of their genes with their environment. The researchers further suggest that resistant hypertension in those with sleep apnea may be caused by a less common gene variant that nonetheless has significant impact.

It’s a hypothesis that will likely be put to the test over the next decade. The researchers who collaborated on the paper all belong to the Sleep Apnea Genetics International Consortium (SAGIC), a partnership of scientists from five continents who are building the first-ever international biomedical database to uncover the genetic causes of sleep apnea. By collecting biological material from thousands of patients with sleep disorders, the group hopes to amass enough data to start identifying underlying genetic causes of different conditions.

“We’re only just now beginning to appreciate the link between sleep apnea and disease,” says Magalang. “We hope that one day we will find common genes shared between people who have uncontrollable blood pressure and sleep apnea, and that will open up a whole new world of interventions and treatment strategies.”

The research was supported by the National Heart, Lung and Blood Institute. Ohio State’s Center for Clinical and Translational Science (CCTS) also provided biomedical informatics support for the study and provides ongoing informatics support for SAGIC.

Sleep Apnea May Reduce Antidepressant Response, Increase Dementia Risk

Published on April 7, 2015

Studies suggest sleep apnea may have a strong influence on antidepressant response and increase the risk for mild cognitive impairment in older patients with major depressive disorder, reports Medscape.

“This shows that clinicians should definitely screen for sleep apnea when patients are presenting with late-life depression,” lead author Lauren Waterman, from the University of Pittsburgh School of Medicine, Pennsylvania, told Medscape Medical News.

Does your dog's snoring keep you awake?

Dogs that snore aren't getting a good night's sleep -- and, chances are, neither are you.

By Stacey Cohen

Stacey Cohen has been a news broadcaster and talk show host for more than 25 years. She has worked with Sally Jesse Raphael, G Gordon Liddy, Martha Stewart, Jane Fonda and many more. She even did play-by-play for the O.J. Simpson trial.

Photo © Tatiana Katsai - Fotolia

For some reason we tolerate our pets' snoring more than we do our spouse's, but it can be the cover-up for an array of issues. Like any problem, if it is something new, it might be worth a trip to the vet to check out. Snoring can have some underlying serious causes.

If your dog is snoring it is some kind of obstruction that is causing the problem. Digging in the dirt, rolling in the grass, even drinking water and eating can introduce foreign objects into your dog’s nasal passage, resulting in snoring. Extra mucus from a cold will also create snoring.

For the most part, snoring caused by nasal obstructions is temporary and should stop when the passage is cleared. There are some other common reasons for snoring:

Dental problems can be a factor. If your dog has bad teeth. It can lead to an abscess. It will go right through the nasal passages. If you don't have your dog’s teeth looked at, dental problems can be a source of infection that goes through your dog’s whole body. Infections can be a host for another set of problems.

Extra pounds

Is your dog carrying a little extra weight? If so, that can be a factor that is causing the snoring. Excess tissue in the throat will cause the obstruction that blocks the airways. As your dog breathes in and out, obesity makes the trachea rings slam shut.

Or it could be a fungus that you may not even be aware of but your dog sure is, such as mold found in hay, grass clippings and similar environments. Left untreated, this fungal disease can cause discomfort, loss of appetite and serious health problems.Any type of upper respiratory problem can cause a blockage, including a temporary inflammation in the nose from a cold or seasonal allergies.

You may have just picked a breed that has this issue through genetics. Because of genetics some breeds may actually have to have a surgery to open up their nasal passages because they are almost completely shut, like a pug or Boston terrier. Brachycephalic breeds -- the breeds with very short noses, such as English/French bulldogs, Boston terriers and pugs -- have a natural tendency to snore.

Is your dog breathing secondhand smoke? Smoke can irritate the nasal passages and make it difficult to breathe. Smoke away from the dog or better yet quit. You both will be healthier.

How can you help your dog breathe more easily? Try giving your dog a pillow. It will elevate the head.

A round bed will encourage a different sleeping position. The round bed will encourage a curled position that allows air passages to expand.

A humidifier can help increase the moisture in the air and help, so the nasal passages won't be so dry.

If your dog is snoring it most likely isn't getting a restful sleep and if it isn't getting good sleep that means you probably aren't either. If the problem persists after trying to change up the sleep environment go back to the vet and see if it is an allergy or if possibly surgery is needed.

Obesity In Children Linked to Lack of Sleep and Breathing Problems

March 7, 2015

A child’s difficulty to sleep and breathing problems can influence the risk of your child from getting obese. The recent research study published in The Journal of Pediatrics revealed that these two conditions may double the risk for obesity of a child as he reaches the age of 15. The lead researcher, Prof. Karen Bonuck, indicated that sleep and breathing problems are correctable conditions, but when not treated accordingly can increase the risk of the child to become obese.

Sleep disordered breathing

Sleep disordered breathing is considered to be a risk factor to child obesity. The condition includes sleep apnea and snoring. Parents of children in the study were asked to provide information involving their child’s sleep duration and sleep disordered breathing symptoms since birth until the child reaches the age of 6 years. Data on body mass index(BMI) were also obtained. The study showed that those with a higher BMI and with severe sleep disordered breathing symptoms are at the greatest risk of getting obese. Their chance to become obese as they reach the age of 7 to 15 years old is twice as much as those who are symptomatic with sleep disordered breathing condition. A study made in Hong Kong revealed that children with an excess weight tend to have a breathing problem because it causes the narrowing or congestion of the child’s airway while sleeping. Children with sleep disorders also tend to have enlarged tissues at the back of their throat, increasing their chance to getting obese later on.

Sleep duration symptoms

Children with a shorter sleep duration at the age of five or six have about 60 to 100 percent of getting obese upon reaching the age of 15. This finding, however, is interestingly not consistent among children of other age group. Short sleep duration in children refers to sleep that is less than 90% than the other children of their age. Parents are advised to help their children get enough sleep at an ideal duration, considering that about 25 to 50 percent of preschoolers suffer from lack of sufficient sleep.

In a research study published in Pediatrics that was conducted by the University of Chicago researchers, the sleeping patterns of about 308 children between the age of 4 and 10 were tracked down using a special wrist device. These children were categorized with normal, overweight and obese according to their respective body mass index. The study revealed that obese children in the group have variable sleep patterns and they tend to have short duration sleep as the other children. They were also identified to have the unhealthiest blood profile during blood extraction.

Additional findings of the researchers show that those children having the tendency to become obese are more protected when they get adequate sleep. Additional observation was added by Dr. Phyllis Zee, a sleep researcher, where he agreed there is a correlating link between sleep and obesity, but also signifies that the variability of sleep-wake timing in children can also be a contributing factor in regulating weight.

Other researches were also focusing on the resulting interrupted or disordered activity of the body’s metabolism and endocrine system caused by the lack of sleep. This is especially significant among children whose body are still growing. Another relation to sleep and obesity are the changes in the levels  of two hormones named leptin and gherlin, which are responsible for appetite and hunger regulation. The body often misinterprets sleep cravings as a hunger that causes an increase in the activities of these hormones that makes a child overeat.

Sleep Apnea More Than Doubles Risk For Car Accidents: The Dangers Of Drowsy Driving

Mar 11, 2015 11:57 AM By Chris Weller

New evidence adds to the already compelling case that driving a car while not properly rested produces similar risks as driving drunk.

The recent study was published in the journal Sleep and found people with obstructive sleep apnea were 2.5 times more likely to be the driver in an accident than people without the sleep disorder. Fortunately, the study also found continuous positive airway pressure, or CPAP, therapy was effective at reducing the rates by up to 70 percent if the person used the technique for an average of four hours every night.

"Excessive daytime sleepiness is a common symptom of obstructive sleep apnea, which can cause you to awaken in the morning feeling tired and unrefreshed despite a full night of sleep," said Dr. Timothy Morgenthale, president of the American Academy of Sleep Medicine, in a statement.

Insufficient sleep has been officially classified as a public health epidemic by the Centers for Disease Control and Prevention, as nearly 40 percent of people report unintentionally falling asleep at least once in the past month. On their own, the dangers of sleep deprivation include a suppressed immune system and moderate cognitive impairment. But the risks increase even further when those setbacks are applied to a complex activity, like driving a car. In 2010, a study found 20 to 25 hours of sleep loss resulted in the same levels of depleted brainpower as a blood-alcohol concentration of 0.10.

Obstructive sleep apnea, a condition in which the body’s airway gets blocked and results in difficulty breathing, may produce many of the same effects. In the latest study, Swedish researchers used data from the long-term data collection project STRADA, the Swedish Traffic Accident Registry. The team looked at 1,478 sleep apnea patients with an average age of 54 years. Comparing accident rates among a control population of more than 635,000, they found drivers in accidents were significantly more likely to suffer from sleep apnea. People who got only five hours of sleep, experienced daytime sleepiness, and regularly took sleeping pills also faced greater accident risks.

"Effective identification and treatment of sleep apnea is essential to reduce avoidable, life-threatening accidents caused by drowsy driving," Morgenthale said.

Obstructive sleep apnea is decidedly less common than general sleep deprivation. Roughlyone in five American adults has a mild case, while one in 15 has a moderate to severe case. Meanwhile, a recent Gallup poll found 40 percent of the country gets less than the recommended amount of sleep each night. Collectively, these missed hours account for 6,400 traffic-related deaths, which make up 21 percent of the U.S. total, according to a 2014 report. This is an increase from the 16.5 percent of deaths a previous 2010 study found.

For the dangers of drowsy driving, drunk driving still remains the greatest danger to motorists. The CDC reports that in 2012, alcohol-impaired drivers led to 10,322 deaths, which accounted for nearly a third of all traffic-related deaths in the U.S. Drunk driving’s annual cost is roughly $59 billion.

Drowsy driving, however, seldom receives a proportional amount of attention as drunk driving, which only adds to the risks. A deepening culture of casual sleepiness may account for Americans’ reluctance to sit passenger just because they feel a little groggy. For people with legitimate sleep disorders like obstructive sleep apnea, the latest research suggests people can dramatically cut their chances of an accident if they can identify their symptoms and take action.

For everyone else, the prescription is as simple as investing an extra hour or two of sleep each night. Given that 90 percent of the U.S. population drives a car to and from work, it’s a quick fix that can end up keeping everyone safe.

Is the Apnea/Hypopnea Index the Best Measure of Obstructive Sleep Apnea?

December 9, 2014


Obstructive sleep apnea (OSA) continues to challenge otolaryngologists and patients alike, with estimates of the condition affecting between 2% and 4% of the adult population in the United States. Gold standard OSA diagnosis is made through a polysomnogram (PSG) test, which uses the apnea/hypopnea index (AHI) as its main defining measure.

The AHI, which quantifies the number of times each hour a patient has a total (apnea) or partial (hypopnea) blockage of breathing during sleep, has been the most-used measure, not only of how OSA is diagnosed, but also of how well treatment modalities, including continuous positive airway pressure (CPAP) and surgery, improve breathing patterns.

Recently, however, some otolaryngologists have been questioning whether the AHI should be the main—and sometimes only—determining factor of treatment effectiveness, or whether other measures such as sleepiness scales, quality of life (QOL) measurements, and physiological measurements such as blood pressure should play a more prominent role.

The Challenges of AHI

Much of the focus around this questioning has arisen not only because of AHI’s value as a measurement index, but also because of its changing definition.

“As an index, the AHI can vary a lot between sleep centers and even within the same sleep center. You’ll get a different number depending on which definition and sensors you use,” said

Ofer Jacobowitz, MD, PhD, assistant clinical professor of otolaryngology at Mount Sinai Hospital in New York City. “Hypopnea can be defined based on either a 30% or 50% decrease in inflow and associated with either a 3% or 4% oxygen desaturation.or even an arousal. The recommended definition of hypopnea has changed multiple times over the years.”

The effects of this shifting definition have been noted in research. In a 2012 study published in The Laryngoscope that examined the effects of different PSG scoring systems on outcome measurement following OSA surgery, the researchers noted that interpretation of OSA surgical treatment literature remains problematic, because the study authors continue to use different AHI criteria for investigation and different AHI thresholds for defining surgical success (Laryngoscope. 2012;122:1878-1881). They found that the success rate for OSA surgical treatment ranged from 38.9% to 91.7%, depending on the criteria and metric used to define a successful outcome.

Another issue is that, even with a stable definition, the AHI number may not represent an accurate picture of an individual patient’s experience with the disease. “The AHI tells you about the sum of apneas and hypopneas, but two patients with the same AHI number may have completely different scenarios—one with mostly apneas and longer or more severe desaturations and one with mostly hypopneas with minimal desaturations,” said Dr. Jacobowitz.

“It used to be thought that the more severe a patient’s sleep apnea, the more sleepy he or she would be, but that turns out not to be the case,” said Eric Kezirian, MD, MPH, professor of clinical medicine in the department of otolaryngology-head and neck surgery at the Keck School of Medicine of the University of Southern California in Los Angeles. “Sleep apnea can reduce the sleep quality for patients, resulting in sleepiness, fatigue, and decreased quality of life. It turns out the AHI doesn’t capture that.”

Part of the issue is that people can be fatigued for a number of reasons, Dr. Kezirian added. They may not be sleeping enough, they may have insomnia, or there may be other sleep issues. “You want to have some objective way to measure how well you’re treating OSA,” he said. “The AHI is certainly part of that; it’s a single number that allows you to get a sense of what a patient’s breathing patterns are like. But we don’t treat numbers, we treat patients, and so we care about the broader implications of the treatment.”

These researchers looked at 21 studies on outcome measures in addition to the AHI that were published between 1997 and 2012. The authors found that patients with OSA scored differently in measurement tools in all categories when compared with control populations or after treatment and that, in general, there was a poor correlation with AHI.

“The issue with AHI is that it’s only part of the definition of OSA—it is a marker of sleep apnea, a surrogate variable of the disease,” said Dr. Jacobowitz. “AHI will remain important because there is reasonable evidence that when a patient’s AHI is over 30, it is associated with increased mortality. But it’s an indirect measure of only the respiratory component of sleep apnea and does not measure sleepiness. For example, if the AHI is less than 15, you can’t make an OSA diagnosis unless the patient has associated symptoms, and that’s exactly what we’re talking about: sleepiness, quality of life, and more.”

Other Measures of OSA

While researchers commonly use AHI, other metrics have been used alongside it to give a broader sense of treatment, according to Dr. Kezirian, including the Epworth Sleepiness Scale and QOL measurement questionnaires. Additional measures also include blood pressure, oxygen desaturation index, psychomotor vigilance tasks, and, over the long term, serious cardiovascular events and mortality.

In clinical application, these other measurements can give a clearer picture of the patient’s reason for seeking treatment, particularly where OSA surgery is concerned. “A sleep study comes from a single night, either in a sleep laboratory where patients are hooked up to many different monitors, or at home where, although there are fewer monitors, it can still be disruptive,” said Dr. Kezirian. “The study may not capture the general pattern of a patient’s sleep over longer periods of time. This single snapshot of one night may not represent what’s typically happening for a particular patient for a number of reasons: Many patients tend to sleep more on their backs during studies and may give an artificially worse picture of their sleep apnea, and there is some disruption of sleep by the monitors, to name just a couple of those reasons. For patients and sleep surgeons considering surgery, there are many gradations of sleep apnea and a number of reasons why the AHI might not capture the effects of treatment, good and bad. That’s why other measures are helpful.”

They are not, however, without their problems, including the fact that the questionnaire measurements are highly subjective and can have a placebo effect. “If a patient undergoes surgery and wants to feel better, they sometimes will,” said Dr. Kezirian. “A better assessment would include a combination of metrics. An otolaryngologist could look at the sleep study result, but also at how that patient is doing overall.”

Looking Forward

“The goals of surgical OSA treatment are the reduction of cardiovascular risk, increased survival, reduced sleepiness, improved quality of life, and, of course, reduced snoring,” said Dr. Jacobowitz. “These can only be captured by using the AHI in conjunction with other quality of life, physiological, and clinical measurements.

So why haven’t alternate metrics been used more often in the clinical assessment of OSA treatment? Dr. Jacobowitz believes it’s a matter of familiarity and ease with using a single quantifiable parameter—the AHI. “The traditional gold-standard treatment of OSA is CPAP [continuous positive airway pressure], and CPAP was designed to improve AHI,” he added.

There is some evidence validating the use of a variety of metrics in outcome measurements. In the 2012 Laryngoscope study, outcomes not only showed a reduction in AHI (in all indices) but also a reduction in patient-reported symptoms. “OSA is not defined solely by a metric; the diagnosis and management of this condition takes into account patient symptomatology as well as disease severity…. Polysomnographic parameters as outcome measures are important surrogates of some clinical outcomes, such as cardiovascular risk, but they should not be mistaken for clinical outcomes themselves,” said the authors. “Similarly, the definition of surgical success should be by more than just the AHI reduction alone, and other outcomes should be included in assessment of postoperative consideration.”

“For CPAP, although you can normalize the AHI in the sleep lab, often there is residual elevated AHI at home and many patients do not use CPAP for the entire night at home,” added Dr. Jacobowitz. “When you look at this AHI variable with regard to sleep surgery outcome, typically the AHI is reduced significantly but doesn’t normalize completely. At the same time, with respect to meaningful primary clinical outcomes, CPAP and surgery can reduce cardiovascular morbidity and decrease the rate of car accidents despite that imperfect AHI reduction.”

For the future, Dr. Kezirian sees more otolaryngologists adopting broader assessments of patients. “These questionnaires have been around for a while, but they are now being used more often in routine clinical practice. They go beyond just asking, ‘How are you doing?’” he said. “Using the questionnaires helps us determine the benefits of treatment if outcomes are not perfect, so we can tell if someone is making progress. The AHI alone is too simplistic. Patients may have no or little change in their AHI but still feel better, but they can also show major improvement in the AHI but still feel awful, which isn’t good enough either.”

Dr. Jacobowitz believes that widespread adoption will come with greater emphasis on alternative measurements in any clinical trial for OSA. “This isn’t difficult for quality-of-life measures, but it will present a challenge for some other variables such as cardiovascular incidents because they must be measured over a very long time,” he said. “But we have to remember what’s important to the patient and for our health system: how the patient is functioning, and the overall status of their health.”

Amy Hamaker is a freelance medical writer based in California.

The Three Different Definitions of AHI

AHIChicago More than 50% decrease in a valid measure of air flow, or a lesser airflow reduction in association with an oxygen desaturation of more than 3%, or an arousal.

AHIRec Abnormal respiratory event lasting 10 seconds or more, with 30% or higher reduction in thoracoabdominal movement or airflow, and with 4% or higher oxygen desaturation.

AHIAlt 50% or higher reduction in nasal pressure signal excursions and 3% or higher desaturation or arousal.

Non-AHI Measurements of OSA

• Biological Measurements (including assessment of hypertension, C-reactive protein, myeloperoxidase, oxygen desaturation, cardiovascular events)
• Measurements of Sleepiness (including the Epworth Sleepiness Scale)
• Performance Measurements (including assessment of motor vehicle collisions and psychomotor vigilance tasks)
• QOL Measurements (including Short Form-36, Nottingham Health Profile, Sickness Impact Profile)

Abstracts from The Laryngoscope

What Is ‘‘Success’’ Following Surgery for Obstructive Sleep Apnea? The Effect of Different Polysomnographic Scoring Systems

ABSTRACT

Objectives/hypothesis: To illustrate that the diagnosis of obstructive sleep apnea (OSA) is dependent on the polysomnographic scoring criteria used, and the success rates of treatments for OSA are dependent on the defined outcome measures.

Study design: Retrospective case series with prospective reanalysis of polysomnographic data.

Methods: Consecutively treated adult patients (N 1/4 40) with moderate to severe OSA having multilevel pharyngeal surgery in 2007 were studied. All patients underwent submucosal lingualplasty and concurrent or previous uvulopalatopharyngoplasty six palatal advancement. Full polysomnography (PSG) was performed preoperatively and at a mean of 145 days postoperatively. Pre- and postoperative PSG data were analyzed by two different but widely used scoring systems for the apnea-hypopnea index (AHI): The American Academy of Sleep Medicine (AASM) 1999 Chicago criteria and the AASM 2007 recommended criteria.

Results: Follow-up PSG data were available in 31 of 40 patients. Successful surgery was defined as a reduction in AHIRec <20 with a 50% reduction from the patient’s baseline, and in this group the surgical intervention was associated with a 72.2% success rate. If, however, differing AHI metrics are used or the absolute or percent reduction used to define a successful outcome is changed, then the rate of surgical success is shown to range from 39% to 92%.

Conclusions: Different criteria for measuring AHI and defining success following OSA surgery can produce widely conflicting outcome data. Reported results following OSA surgery should be interpreted with this in mind. Using acceptable criteria, multilevel sleep surgery can be demonstrated to be of benefit to the majority of carefully selected patients. (Laryngoscope. 2012;122:1878-1881).

Outcome Measurements in Obstructive Sleep Apnea: Beyond the Apnea-Hypopnea Index

ABSTRACT

Objectives/hypothesis: The apnea-hypopnea index (AHI) is overwhelmingly used as the main therapeutic metric in the assessment of obstructive sleep apnea (OSA) in surgical studies. However, using AHI as the sole measure is problematic. This study investigates the utility of other outcome measures for patients with OSA undergoing surgery.

Study design: Systematic review of cohort and review studies.

Methods: A review was performed using the PubMed database. English articles focusing on outcome measures in adults with OSA were included. Studies in pediatric populations, those combining obstructing and central sleep apnea, and those without the use of outcome measures were excluded. Articles were categorized according to level of evidence. The Downs and Black scale and AMSTAR scale were used to assess quality.

Results: Of a total of 10,454 retrieved articles, 21 studies met inclusion and exclusion criteria. Most articles related to continuous positive airway pressure outcomes. Many categories of outcome measures were found: general quality of life, OSA-specific quality of life, measurements of sleepiness, performance, and physiological. Subjects with OSA scored differently in measurement tools in all categories compared to control populations or after treatment, and generally a poor correlation with AHI was seen.

Conclusions: The literature shows a range of tools based on symptoms and physiology of OSA that can assess effects of treatment. Assessment of surgical treatment for OSA should neither be limited to AHI as an outcome, nor should this be the only outcome stressed (Laryngoscope. 2014;124:337-343).

Changes in Obstructive Sleep Apnea Severity, Biomarkers, and Quality of Life After Multilevel Surgery

ABSTRACT

Objectives/hypothesis: To evaluate the impact of multilevel obstructive sleep apnea surgical treatment on sleep-disordered breathing severity, health-related measures, and quality of life, and to examine the association between changes in sleep-disordered breathing severity and these other outcomes.

Study design: Prospective cohort study.

Methods: Subjects with obstructive sleep apnea unable to tolerate positive airway pressure therapy and with evidence of multilevel (palate and hypopharynx) obstruction underwent uvulopalatopharyngoplasty, tonsillectomy, and genioglossus advancement, with or without hyoid suspension. All subjects had preoperative and postoperative study assessments, including blood draw for C-reactive protein, interleukin-6, homocysteine, homeostasis model of insulin resistance, and leptin, and evaluation with the Functional Outcomes of Sleep Questionnaire.

Is the Apnea/Hypopnea Index the Best Measure of Obstructive Sleep Apnea?

Results: Thirty subjects underwent multilevel surgical treatment. The mean apnea-hypopnea index decreased from 44.9 ± 28.1 to 27.8 ± 26.4 events/hour (P = .008). Thirteen (43%) subjects in this heterogeneous sample achieved a response to surgery (defined as an apnea-hypopnea index reduction of ≥50% to an absolute level less than 15 events / hour and body mass index ≤32 kg/m2 was associated with a higher likelihood (55%, 12/22) of response (P = .04). There was no overall change in C-reactive protein levels, but responders demonstrated a decrease (−1.02 ± 0.98 mg/L, P = .003) that was independent of changes in body weight. There were no significant changes in other health-related measures. Responders and nonresponders both demonstrated improvements in sleep-related quality of life.

Depression, Sleepiness, and Disease Severity in Patients with Obstructive Sleep Apnea

ABSTRACT

Objectives/hypothesis: To determine if a relationship exists between depression, disease severity, and sleepiness in patients with obstructive sleep apnea (OSA).

Study design: Case control study.

Methods: Fifty-three consecutive patients with suspected OSA were evaluated before treatment and compared with controls by using the Beck Depression Inventory (BDI), Epworth Sleepiness Scale (ESS), and polysomnography.

Results: OSA was associated with an increased risk of depression in the study group compared to the control group (odds ratio = 6.3, 95% confidence interval: 1.9-20.6, P = .002); depression was seen in 35% of OSA patients and 8% of controls (P < .001). There was a significant correlation between BDI and ESS scores (r = 0.342, P = .012). In addition, ESS was significantly associated (P = .039) with depression in a linear regression model that controlled for race, sex, age, and respiratory disturbance index (RDI). RDI and depression were weakly associated (P = .056) in this model, and there was no correlation found between BDI scores and OSA disease severity (RDI)(r = 0.446).

Conclusions: Patients with OSA and daytime sleepiness are more likely to have depressive symptoms as compared with controls. OSA disease severity, as measured with the RDI score, is a weak predictor of BDI score, and no correlation was seen between the severity of OSA and BDI scores after controlling for other factors. However, there was a strong correlation between sleepiness (ESS) and disease severity (BDI). These data suggest that OSA patients with symptoms of excessive sleepiness have the highest risk of associated depressive symptoms and may benefit most from depression screening (Laryngoscope. 2010:120:2331-2335).

Poor Quality Sleep Could Lead To Brain Changes And Dementia, Study Finds

Posted: 12/10/2014 4:08 pm EST Updated: 12/10/2014 4:59 pm EST

It's bad enough being one of the millions of people suffering from sleep-disturbing conditions like emphysema and sleep apnea, waking up tired or having your spouse complain about your loud snoring. Now a new study reveals even scarier effects of not getting enough quality sleep.

Findings unveiled today in the journal Neurology, links the effects of sleep disturbances to brain changes that could lead to dementia later in life. Researchers looked at a cohort of 167 Japanese-American men with an average age of 84, following the mens' sleep patterns from the start of the study until their death, an average of six years later.

They found that lower blood oxygen levels at night, due to sleep disturbances, made men more likely to have harmful brain changes. The men with the lowest levels of blood oxygen were four times as likely to have brain abnormalities than men with higher levels. Those who had less deep sleep, or "slow wave sleep," were also more likely to have lost brain cells.

"These findings suggest that low blood oxygen levels and reduced slow wave sleep may contribute to the processes that lead to cognitive decline and dementia," study author Rebecca P. Gelber of the VA Pacific Islands Health Care System said in a release. "More research is needed to determine how slow wave sleep may play a restorative role in brain function and whether preventing low blood oxygen levels may reduce the risk of dementia."

Various studies have cautioned of the negative effects of lack of quality sleep on the brain. A Temple University study found that mice who were sleep deprived showed more plaques and tangles in the brain, a hallmark of Alzheimer's, as well as memory problems, in just eight weeks. Another study found that in older men, sleep disturbances increased the risk of Alzheimer's by up to 50 percent.

The researchers say that more studies could show whether or not getting more quality sleep or increasing blood oxygen levels could actually have the reverse effect on brain changes. Until then, let's all try to get a better night's rest.

IMPROVING YOUR SLEEP

Get Moving
Exercise 30 minutes a day. Nothing exotic is required; a good half-hour stroll will do the trick, but avoid exercising within three to four hours of bedtime.

Limit Caffeine
Limit the use of all caffeinated beverages (coffee, tea, soft drinks) throughout the day and do not consume any after lunch.

Talk To Your Doctor
Check all of your medicines with your doctor to see if they could be affecting your sleep.

Make The Bedroom A Bedroom
Use the bedroom just for sleep. It may be time to invest in earplugs, an eye mask or even heavier curtains to block out extra light and sound. Don't be afraid to give fidgeting pets the boot and avoid eating, watching television or finishing work in the bedroom.

Adjust Room Temperature
Make sure your bedroom is cool, dark and quiet. Try adjusting the temperature of the bedroom for a more optimal sleeping environment. (For easier temperature regulation throughout the night, ditch the singular heavy comforter and opt for piling on light layers that can be easily kicked off as needed.)

Sign Off
Every night budget a "pre-sleep" period of time (say, a half-hour) to read a book or watch the TV news, and then go to the bedroom with lights out after the period is up. 


Don't ruminate. Practice "thought-stopping"where you only allow yourself to worry about a problem during daytime hours. Refrain from checking texts and e-mails (physically banish your cell to a different room if necessary!) before and during your bedtime routine.

Notes from Dr. Norman Blumenstock
Athletes, Take Note: Sleeping More Can Give You a Competitive Edge

Visit the Fitness Video Library

By Dr. Mercola

Athletes, take note: if you want to optimize your athletic performance, be sure to get your zzz’s. As noted by The Atlantic:1

“Without proper sleep, whether it’s a short-term or long-term deficit, there are substantial effects on mood, mental and cognitive skills, and motor abilities. When it comes to recovery from hard physical efforts, there’s simply no better treatment than sleep, and a lot of it.”

Not surprisingly, sleep deprivation has a detrimental effect on sports performance across the board, but certain types of athletes see a particularly marked drop in performance if they skimp on sleep.

The largest performance drop-offs can be seen among endurance athletes, and sports requiring quick reaction times and reflexes.

Non-athletes will also optimize their health and longevity by paying attention to the quality of their sleep. In fact, getting enough sleep appears to be key for aging well, and maintaining healthy brain and body into old age.

Competitive Athletes Get a Leg Up with More Sleep

To determine whether an athlete might gain a competitive edge simply by sleeping more, Stanford researcher Cheri D. Mah reached out to The Cardinal’s men’s basketball team.

For two weeks, the players’ athletic performance was assessed after getting their normal amount of sleep. They were fitted with motion-sensing wristbands to determine the actual length of their sleep, which averaged in at a mere 6.5 hours per night.

Next, the players were asked to extend their sleep time as much as possible for five to seven weeks. The players increased their average sleep time by about two hours—to 8.5 hours nightly. As reported in the featured article:

“The results were startling. By the end of the extra-sleep period, players had improved their free throw shooting by 11.4 percent and their three-point shooting by 13.7 percent. There was an improvement of 0.7 seconds on the 282-foot sprint drill—every single player on the team was quicker than before the study had started.

A 13-percent performance enhancement is the sort of gain that one associates with drugs or years of training—not simply making sure to get tons of sleep. Mah’s research strongly suggests that most athletes would perform much better with more sleep...”

Unfortunately, extensive and hectic travel schedules usually make sleep hard to come by when you’re a competitive athlete. While not an ideal alternative to getting a solid night’s sleep, taking naps whenever possible can help.

For the majority of you though, who are not professional athletes, research like this shows just how important it is to get enough sleep. If athletes can improve their professional performance by sleeping more, the same will apply to “regular folks” as well.

The Importance of Staying in Sync with Nature

Maintaining a natural rhythm of exposure to sunlight during the day and darkness at night is one crucial foundational component of sleeping well. This was addressed in a previous interview with Dan Pardi, a researcher who works with the Behavioral Sciences Department at Stanford University and the Departments of Neurology and Endocrinology at Leiden University in the Netherlands.

Exposure to bright daylight synchronizes your master clock—a group of cells in your brain called the suprachiasmatic nuclei (SCN). These nuclei synchronize to the light-dark cycle of your environment when light enters your eye. You also have other biological clocks throughout your body, and those clocks subsequently synchronize to your master clock.

One reason why so many people get so little sleep, and/or such poor sleep, can be traced back to a master clock disruption. One lifestyle factor that can significantly hamper your sleep is spending the entire day indoors in an area with few or no windows.

That, combined with spending your evenings in too-bright artificial light, is a surefire way to get out of sync with the natural rhythm of daylight and nighttime darkness. The end result is difficulty falling or staying asleep when it’s time for bed, and persistent daytime sleepiness.

Improve Your Sleep Hygiene with a Fitness Tracker

Getting enough sleep is really crucial to overall good health; I strongly recommend taking the matter seriously. While overuse of light-emitting technology is part of the problem, some gadgets can actually help you improve your sleep hygiene.

We’re about to see an explosion of fitness trackers hitting the market, and I believe this can be a really good thing, provided you make good use of it.

There are already a few good ones available, but even better versions are sure to follow. The Apple Watch being launched next year is one example. Currently, one of the best is Jawbone’s Up32—it’s definitely among the most advanced fitness tracker to date.

This lightweight wristband keeps track of a wide variety of data, including exercise, hydration levels, and REM sleep. The data collected can even tell you what activities led to your best sleep, and what factors resulted in poor sleep.

With this kind of data at hand, you can start making some really healthy choices. The Smart Coach will also remind you when it’s time to hit the sack. Besides tracking your sleep patterns, a fitness tracker can also inspire you to get enough movement into your day-to-day life.

A Fitness Tracker Can Help You Lead a More Active Lifestyle

Overwhelming evidence shows that prolonged sitting is an independent risk factor for chronic health problems and a shorter lifespan, so regularly getting off your chair is just as important as having a regular workout schedule.

While some experts in this field recommend standing up at least 10 minutes out of every hour of sitting, I believe this may not be enough for optimal health. Personally, I now try to sit as little as possible. I strive to sit less than one hour per day, which is an achievable goal unless I’m travelling and am forced to sit in a plane or car.

Simply standing up has had the remarkable effect of “curing” my chronic back pain, which I’ve struggled with for many years. It would normally start after I’d walk or stand for more than 30 minutes, but since I reduced my sitting, the pain has essentially disappeared. 

Prior to this simple intervention, I’d tried four different chiropractors, posture exercises, Foundation Training, ab work, inversion tables, standing up every 15 minutes to stretch, and strength training. Yet the improvements were minimal. I’m still surprised I missed this important health principle for so long! Another recent epiphany I had is that most of us need to walk much more than we do. This is where a fitness tracker can be very helpful, as it allows you to objectively record how much you walk.

Most of us need about 7,000-10,000 steps a day, which is about four to five miles (6-9 km). Keep in mind that this is walking is in addition to, not in place of, your normal exercise program. If you can, consider walking barefoot, as this will help you get grounded—it’s even better if you can walk on the beach by the ocean. I believe the combination of high intensity training, non-exercise activities like walking 10,000 steps a day, along with avoiding sitting whenever possible is the key to being really fit and enjoying a pain free and joyful life. If you don't have a fitness tracker that records your steps and your sleep, I would encourage you to get one.

Beware of Sleeping Pills...

While most would not knowingly put their life on the line, you may be doing just that if you take sleeping pills. They’re simply NOT a viable alternative to synchronizing your sleep rhythm to the natural cycle of light and darkness... According to the statistics3 from the Centers for Disease Control and Prevention (CDC), between 50 and 70 million Americans suffer from sleep deprivation, and nearly nine million Americans take prescription sleeping pills in pursuit of good night’s rest.

Unfortunately, the price you may end up paying for taking this “shortcut” could be higher than expected. A study4 by the Substance Abuse and Mental Health Services Administration (SAMHSA) reveals that emergency room visits involving the sleep aid zolpidem nearly doubled between 2005 and 2010, reaching 42,274 visits in the year 2009-2010. Zolpidem is the active ingredient in sleep aids sold under brand names like Ambien, Ambien CR, Edluar, and Zolpimist. Polypharmacy—the use of multiple drugs—is part of the problem. In 57 percent of these overmedication cases, there were additional drugs involved:

• In 26 percent of cases, zolpidem was combined with benzodiazepines (Valium, Xanax, Ativan, etc.)
• 25 percent involved a combination with narcotic pain relievers
• Alcohol was also used in 14 percent of these emergency room visits

Sleeping Pill Use and Driving Can Be a Dangerous Mix

Recent research also shows that prescription drugs are involved in fatal car crashes at three times the rate of marijuana, and sleeping pills are among the drugs that could turn you into a danger on the road. Studies submitted to the FDA have revealed that blood levels of zolpidem above 50 ng/mL may impair your driving to a degree that increases the risk of an accident, especially among women. As a result, FDA recommended manufacturers cut the dosage of zolpidem from 10mg to 5mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR).5

A 2013 CDC report6 also estimated that up to one-third of all fatal car crashes involve a drowsy driver, and daytime drowsiness is a very common side effect of sleeping pills. Other side effects associated with zolpidem include dizziness, hallucinations, agitation, and sleep-walking. It’s also important to realize that narcotic pain relievers and anti-anxiety drugs or sedatives can cause a dangerous enhancement of sleeping pills’ sedative effects.7 Sleeping pills have also been linked to a 35 percent increased cancer risk, along with a greatly increased risk of death from any cause.

Helpful Tips to Improve Your Sleep

My advice is to skip the medication and focus your attention on lifestyle changes that will allow you to get the best sleep possible. Remember, to sleep well, you need to have properly aligned circadian rhythms, and to achieve that, you need to get daylight exposure, ideally around solar noon, for a minimum of 30-60 minutes each day. In the evening, once the sun has set, dim all artificial light sources. In particular, you want to avoid the blue light wavelength.

Research shows that exposure to bright room light before bedtime suppresses melatonin production in 99 percent of individuals, which can rob you of sleep by preventing sleepiness. For night-time lighting, use blue-blocking light bulbs, dim your lights with dimmer switches and turn off unneeded lights, and if using a computer, install blue light-blocking software like f.lux.8 Also keep in mind that digital alarm clocks with blue light displays could have a detrimental effect. The following infographic, created by BigBrandBeds.co.uk, illustrates how your electronic gadgets wreak havoc on your sleep when used before bedtime.9

How Technology Affects Sleep - An infographic by the team at Big Brand Beds