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Authors refer the current level of diagnosis and therapy of sleep apnea syndrome in Germany. The sleep labs are perfectly equipped with recently developed diagnostic systems. Also the treatment of patients with CPAP system (continuous positive airways pressure) is very good organized.
The suprachiasmatic nuclei (SCN) residing in the anterior hypothalamus maintains a near-24-h rhythm of electrical activity, even in the absence of environmental cues. This circadian rhythm is generated by intrinsic molecular mechanisms in the neurons of the SCN; however, the circadian clock is modulated by a wide variety of influences, including glutamate and pituitary adenylate cyclase-activating peptide (PACAP) from the retinohypothalamic tract, melatonin from the pineal gland, and neuropeptide Y from the intergeniculate leaflet. By virtue of these and other inputs, the SCN responds to environmental cues such as light, social and physical activities. In turn, the SCN controls or influences a wide variety of physiologic and behavioral functions, including attention, endocrine cycles, body temperature, melatonin secretion, and the sleep-wake cycle. Regulation of the sleep-wake cycle by the SCN has important implications for development of therapies for sleep disorders, including those involving desynchronization of circadian rhythms and insomnia.
Insomnia is a problem in all stages of life but is particularly common after age 65. A number of factors--including advanced age, psychosocial influences, medical illness, and the use of medications and alcohol--may disturb sleep architecture. Evaluation of insomnia in the older patient requires a careful history and physical examination, supplemented by a sleep diary. Treatment of underlying conditions and nonpharmacologic improvements in sleep hygiene are first-line therapy, but pharmacologic agents such as benzodiazepines, nonbenzodiazepine hypnotics, or antidepressants may be needed. Nonbenzodiazepines with rapid elimination may offer a lower side-effect profile than other hypnotic agents when used for insomnia in the older population.
Sleep disturbances are a particularly common problem in the elderly. The purpose of this study was to examine the effectiveness of auricular therapy on sleep behaviors in the elderly. One hundred and twenty participants of 60 years old or above and who were suffering from sleep disturbances were invited to participate in this study. Eligible participants were randomly allocated to receive auricular therapy using Junci Medulla (Group A = 30), Semen Vaccariae (Group B = 30) or magnetic pearls (Group C = 60). Groups A and B were the control groups, while Group C was the experimental group. Seven auricular points which are thought to have an effect on promoting sleep were selected. The total treatment course lasted for three weeks. Objective measurement using actigraphic monitoring was performed before the therapy commenced, in the middle period of the therapy, and within one week after the therapy had been completed. After the therapy, there were significant differences among the three groups in terms of the nocturnal sleep time (NST) (F(2,117) = 6.84, p < 0.05) and sleep efficiency (SE) (F(2,117) = 7.69, p < 0.05). Significant improvement in the sleep behaviors was observed in the experimental group using magnetic pearls. In a backward multiple regression, the effect of auricular therapy on SE after allowing for age in female participants is of high statistical significance (F(3,106) = 9.04, p < 0.001). The paper concludes that auricular therapy using magnetic pearls is an effective means of improving the quantity and quality of sleep in the elderly.
The investigated patients did not demonstrate a common turning point of mood in the night of sleep deprivation therapy. The antidepressant effect of SD does not occur before the end of the night of SD. No critical period for changes of mood between 2 a.m. and 4 a.m. were found. Retrospective interviews of patients concerning the completed night of SD are problematic.
Results are presented of the study of catecholamine system in endogenic depressive patients before and after treatment with sleep deprivation (26 patients) of tricyclic antidepressants (30 patients). Epinephrine, norepinephrine, and DOPA excretion were studied as related to clinical picture of the syndrome (2 groups: melancholic and anesthetic depressions). Sleep deprivation therapy was an effective method, as indicated by both clinical and catecholamine system signs.
Obstructive sleep apnea is characterized by the repetitive collapse of the upper airway during sleep. A variety of nonsurgical treatments for obstructive sleep apnea have been developed, including behavioral therapies, continuous positive airway pressure (CPAP) devices, oral appliances and medications. Presently, CPAP is considered the first-line treatment for moderate to severe sleep apnea and one of the first-line treatments for mild disease. However, the effectiveness of CPAP is compromised because a large proportion of patients cannot tolerate the devices. Oral appliances are one of the first-line therapies for mild sleep apnea and a treatment for more severe disease if CPAP cannot be tolerated. Medications have thus far been unsuccessful as a treatment option for sleep apnea. All patients should be counseled to avoid sleep deprivation and sedatives (including alcohol) and to lose weight if obese.
A significant number of patients with obstructive sleep apnea neither tolerate positive airway pressure (PAP) therapy nor achieve successful outcomes from either upper airway surgeries or use of an oral appliance. The purpose of this paper, therefore, was to systematically evaluate available peer-reviewed data on the effectiveness of adjunctive medical therapies and summarize findings from these studies. A review from 1985 to 2005 of the English literature reveals several practical findings. Weight loss has additional health benefits and should be routinely recommended to most overweight patients. Presently, there are no widely effective pharmacotherapies for individuals with sleep apnea, with the important exceptions of individuals with hypothyroidism or with acromegaly. Treating the underlying medical condition can have pronounced effects on the apnea/hypopnea index. Stimulant therapy leads to a small but statistically significant improvement in objective sleepiness. Nonetheless, residual sleepiness remains a significant health concern. Supplemental oxygen and positional therapy may benefit subsets of patients, but whether these therapies reduce morbidities as PAP therapy does will require rigorous randomized trials. PAP therapy has set the bar high for successful treatment of sleep apnea and its associated morbidities. Nonetheless, we should strive towards the development of universally effective pharmacotherapies for sleep apnea. To accomplish this, we require a greater knowledge of the neurochemical mechanisms underlying sleep apnea, and we must use this infrastructure of knowledge to design well-controlled, adequately powered studies that examine, not only effects on the apnea/hypopnea index, but also the effects of pharmacotherapies on all health related outcomes shown beneficial with PAP therapy.
BACKGROUND: In the treatment of obstructive sleep apnoea syndrome (OSA) nasal ventilation therapy (nCPAP) and various surgical strategies like uvulopalatopharyn-goplasty proved effective. However, not all patients can be successfully treated with these therapies. In our study we investigated the effects of oral theophylline taken at night in patients with OSA. PATIENTS AND METHODS: 50 patients with polysomnographically verified OSA were enrolled in two groups in this study. In the therapy group we administered 300-500 mg of oral theophylline at night for 4-22 weeks. In all patients nCPAP therapy was indicated in the beginning of the trial. RESULTS: We found a positive effect of theophylline treatment in patients with a comparatively low apnoea-hypopnoea index, low overweight and inconspicuous status of the upper airways. In 5 cases the initially indicated nCPAP treatment could be cancelled. In the therapy group the number of apnoea and hypopnoea was reduced by 17.08%. The mean apnoa duration and the time of sleep with an oxygen saturation below 90% was reduced by 8.41% and 19.58%, respectively. In the control group we found an increase in apnoeas and hypopnoeas by 10.48%. Apnoea duration and desaturation time increased by 4.71% and 11.04%, respectively. Comparison of the effects between the two groups using the Wilcoxon 2-sample test proved to be statistically significant. Besides these positive effects we found 27.2% non-responders. CONCLUSION: Theophylline has a short-term relevant beneficial effect only on patients with mild OSA. Because of the limited beneficial effects, permanent theophylline treatment has to be monitored regularly via control polysomnography. Under certain conditions noctural oral administration of theophylline may supplement conventional therapy strategies.
The antidepressant response to partial sleep deprivation early in the night (PSD-E) was compared with the response to partial sleep deprivation late in the night (PSD-L) in 16 drug-free depressed inpatients using a balanced order crossover design. PSD-L had a significantly greater antidepressant effect that PSD-E. The response to PSD-L was sustained and enhanced by a second night of treatment. Patients had significantly shorter sleep durations and reduced REM sleep on PSD-L that did not occur in the PSD-E situation. There was a significant negative correlation between response to PSD and sleep duration, and in particular, REM sleep duration, in the late sleep deprivation situation. Thus, the amount and timing of sleep appear to be factors in the response to PSD, but additional studies are needed to evaluate the relative importance of these parameters.
160 unselected patients under suspicion of sleep apnea were examined polysomnographically, 26 patients (16%) had relevant psychic disorders, which were classified according to ICD-10 by the psychiatric consultant. Affective-depressive disorders (n = 12) and neurotic disorders (n = 11) were diagnosed. Depression in 3 patients was primarily diagnosed in the sleep laboratory. A proper anamnesis can supply the doctor with helpful hints for psychic disorders. These disorders can complicate or prevent the diagnosis and therapy in the sleep laboratory.
This contribution focuses on psychological aspects which can underlie disturbed sleep or may occur reactively to somatically determined insomnia. Therefore, treatment of insomnia should start out with several explanatory interviews with the patient, in which all subjective evaluations of sleep and associated events are investigated carefully. During several weeks the patient assesses his sleep quality, sleep-related behaviours and mood by means of questionnaires. This information is to be considered in the further diagnostic process and helps to choose adequate therapeutic interventions. Therapeutic help includes a broad variety of possible steps: general information about sleep, sleep hygiene rules, relaxation advice, cognitive techniques or psychotherapy.
This review reports, with as much detail as possible, on the literature relating to therapeutic sleep deprivation (or induced-wakefulness therapy) since it was first described in 1971. The antidepressive effect of sleep deprivation has been substantiated by numerous studies. A series of clinical predictors of response to sleep deprivation are also described. Partial sleep deprivation late in the night is equivalent to total sleep deprivation in terms of therapeutic value and--because of its simpler application--can be regarded today as the sleep deprivation method of choice. The status of sleep deprivation in the overall treatment schedule for depressive disorders is discussed in detail. Numerous findings, some of them contradictory, have been published on the effect of sleep deprivation on biological variables. To date, no unequivocal explanation has been found for the mechanism of action of sleep deprivation.
This study describes, and examines the initial efficacy of, a sleep therapy programme developed for cancer patients with insomnia. The six-session group programme included stimulus control therapy, relaxation training, and other strategies aimed at consolidating sleep and reducing cognitive-emotional arousal. The 12 final participants were patients of a regional cancer centre; mean age was 54.7 years (S.D. 10.4); median time from cancer diagnosis was 33.6 months; all had high performance status. Participants kept sleep diaries and rated their sleep quality, mood and functioning at baseline, week 4 and week 8. Significant improvement over baseline was observed at weeks 4 and 8 in the number of awakenings, time awake after sleep onset, sleep efficiency, sleep quality ratings, and scores on European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 role functioning and insomnia. Total sleep time and fatigue were significantly improved at week 8. The sleep therapy programme was associated with improved sleep, reduced fatigue and enhanced ability to perform activities in relatively well individuals attending a cancer centre. This is preliminary evidence of the efficacy of the programme. Further research is required to examine the programme's effectiveness and suitability for a wider range of people with cancer. Options for providing cancer patients with access to nonpharmacologic treatments for insomnia are discussed.
Parkinson's disease (PD) is associated with sleep disorders which are attributed mainly to dopamine deficiency, nocturnal akinesia, drug therapy, and cofactors such as age and depression. These disturbances affect the macro- and microstructure of both REM and non-REM sleep and motor, respiratory, and autonomic functions. Excessive daytime sleepiness and the interactions between sleep and daytime motor performance in PD are not yet completely understood. Correct diagnosis and treatment of sleep disorders is essential due to the risk of harm to the patient and others and due to their effect on quality of life for all concerned. As sleep disorders in PD are extremely common (about 70%) and may have severe consequences, a systematic sleep history and specific therapy should be considered integral to treatment in every PD patient.
Fourteen inpatients with dementia showing sleep and behavior disorders (average age = 75 years), and 10 control elderly people (average age = 75 years) were carefully observed for 2 months. Four weeks of morning light therapy markedly improved sleep and behavior disorders in the dementia group. The measurement of sleep time and the serum melatonin values suggests that sleep and behavior disorders in the dementia group are related to decreases in the amplitude of the sleep-wake rhythm and decreases in the levels of melatonin secretions. Morning light therapy significantly increased total and nocturnal sleep time and significantly decreased daytime sleep time. These results indicate that morning bright light is a powerful synchronizer that can normalize disturbed sleep and substantially reduce the frequency of behavior disorders in elderly people with dementia.
There is evidence that theophylline improves obstructive sleep apnoea, although the existing studies are not comparable because of different patient groups, methods and treatment regimes and therefore may give partly conflicting results. In our opinion, patients with mild or moderate sleep apnoea syndrome, who do not need nasal ventilation therapy urgently, or who are not at a high cardiovascular risk, are the favourite group for theophylline therapy and an attempt in oral treatment in this group of patients is recommendable, since all other drugs have failed. Serum theophylline level should be lower than in anti-obstructive therapy, because of its otherwise deleterious effect in sleep structure. The improvement in apnoea index, when responding is not only a short-term effect, but lasts over a long-term treatment period, although patients should still be monitored, because of the possibility of worsening in some cases. The reason for responding and not responding in different patients remains unclear, and further studies are needed to investigate the precise mechanisms of action of theophylline in sleep apnoea, which include central and peripheral effects, to establish predictors for treatment in different groups of sleep apnoea patients.
Insomnia is the most common sleep complaint reported to physicians. Treatment has traditionally involved medication. Behavioral approaches have been available for decades, but lack of physician awareness and training, difficulty in obtaining reimbursements, and questions about efficacy have limited their use. These practice parameters review the current evidence with regards to a variety of nonpharmacologic treatments for insomnia. Using a companion paper which provides a background review, the available literature was analyzed. The evidence was graded by previously reported criteria of the American Academy of Sleep Medicine with references to American Psychological Association criteria. Treatments considered include: stimulus control, progressive muscle relaxation, paradoxical intention, biofeedback, sleep restriction, multicomponent cognitive behavioral therapy, sleep hygiene education, imagery training, and cognitive therapy. Improved experimental design has significantly advanced the process of evaluation of nonpharmacologic treatments for insomnia using guidelines outlined by the American Psychological Association (APA). Recommendations for individual therapies using the American Academy of Sleep Medicine recommendation levels for each are: Stimulus Control (Standard); Progressive Muscle Relaxation, Paradoxical Intention, and Biofeedback (Guidelines); Sleep Restriction, and Multicomponent Cognitive Behavioral Therapy (Options); Sleep Hygiene Education, Imagery Training, and Cognitive Therapy had insufficient evidence to be recommended as a single therapy. Optimal duration of therapy, who should perform the treatments, long term outcomes and safety concerns, and the effect of treatment on quality of life are questions in need of future research.