Sleep Medicine

BOSTON – Late chronotype may have a deleterious impact on glucose homeostasis independent of obesity in preadolescents aged 10-13 years, according to a small study.

Late chronotype – or an individual’s preference for later sleep and food intake – is associated with higher body mass index (BMI), risk incidence of type 2 diabetes mellitus, hemoglobin A1c, and risk of hypertension in adults. It is also associated with higher BMI, lower dietary restraint, and lower HDL cholesterol in adolescents. This study was the first to focus on chronotype and glycemic control in children on the cusp of or in early puberty.

In participants tested during the summer months, the actigraphy-derived mid-sleep time on free days – an objective measure of chronotype – was associated positively with fasting plasma glucose (P = 0.048). “This is an important point because it highlights the objective measure of chronotype, whereas questionnaires can be more subjective,” said Magdalena Dumin, MD, at the annual meeting of Associated Professional Sleep Societies.

Debra L. Beck/Frontline Medical News

BOSTON – Late chronotype may have a deleterious impact on glucose homeostasis independent of obesity in preadolescents aged 10-13 years, according to a small study.

Late chronotype – or an individual’s preference for later sleep and food intake – is associated with higher body mass index (BMI), risk incidence of type 2 diabetes mellitus, hemoglobin A1c, and risk of hypertension in adults. It is also associated with higher BMI, lower dietary restraint, and lower HDL cholesterol in adolescents. This study was the first to focus on chronotype and glycemic control in children on the cusp of or in early puberty.

In participants tested during the summer months, the actigraphy-derived mid-sleep time on free days – an objective measure of chronotype – was associated positively with fasting plasma glucose (P = 0.048). “This is an important point because it highlights the objective measure of chronotype, whereas questionnaires can be more subjective,” said Magdalena Dumin, MD, at the annual meeting of Associated Professional Sleep Societies.

Debra L. Beck/Frontline Medical News

BOSTON – Late chronotype may have a deleterious impact on glucose homeostasis independent of obesity in preadolescents aged 10-13 years, according to a small study.

Late chronotype – or an individual’s preference for later sleep and food intake – is associated with higher body mass index (BMI), risk incidence of type 2 diabetes mellitus, hemoglobin A1c, and risk of hypertension in adults. It is also associated with higher BMI, lower dietary restraint, and lower HDL cholesterol in adolescents. This study was the first to focus on chronotype and glycemic control in children on the cusp of or in early puberty.

In participants tested during the summer months, the actigraphy-derived mid-sleep time on free days – an objective measure of chronotype – was associated positively with fasting plasma glucose (P = 0.048). “This is an important point because it highlights the objective measure of chronotype, whereas questionnaires can be more subjective,” said Magdalena Dumin, MD, at the annual meeting of Associated Professional Sleep Societies.

Debra L. Beck/Frontline Medical News

BOSTON – Teenagers slept more hours when they started school later, a new study found.

With 73% of high schoolers reporting receiving less than the recommended 8 hours of sleep per night, teens are among the most sleep-deprived members of society.

In this study, the later a teenager started school, the later he or she woke up, with average wake-up times having been just after 6:00 a.m. for those starting school between 7:00 and 7:30 a.m. and about 7:00 a.m. for those starting school after 8:30 a.m. But only those teens who started after 8:30 a.m. achieved the 8-hour recommended sleep duration, said Nicole Nahmod, during a presentation at the annual meeting of the Associated Professional Sleep Societies.

The students with the later school start times averaged 32 minutes of extra sleep, when compared with their early-rising colleagues, noted Ms. Nahmod, who is one of the study’s authors, a research technician, and study coordinator at Pennsylvania State University, Hershey. Specifically, adolescents who started school after 8:30 a.m. had a mean sleep duration of 8.1 hours, while those who started school earlier slept for only 7.5 hours a night.*

*This article was updated on June 6, 2017.

BOSTON – Teenagers slept more hours when they started school later, a new study found.

With 73% of high schoolers reporting receiving less than the recommended 8 hours of sleep per night, teens are among the most sleep-deprived members of society.

In this study, the later a teenager started school, the later he or she woke up, with average wake-up times having been just after 6:00 a.m. for those starting school between 7:00 and 7:30 a.m. and about 7:00 a.m. for those starting school after 8:30 a.m. But only those teens who started after 8:30 a.m. achieved the 8-hour recommended sleep duration, said Nicole Nahmod, during a presentation at the annual meeting of the Associated Professional Sleep Societies.

The students with the later school start times averaged 32 minutes of extra sleep, when compared with their early-rising colleagues, noted Ms. Nahmod, who is one of the study’s authors, a research technician, and study coordinator at Pennsylvania State University, Hershey. Specifically, adolescents who started school after 8:30 a.m. had a mean sleep duration of 8.1 hours, while those who started school earlier slept for only 7.5 hours a night.*

*This article was updated on June 6, 2017.

BOSTON – Teenagers slept more hours when they started school later, a new study found.

With 73% of high schoolers reporting receiving less than the recommended 8 hours of sleep per night, teens are among the most sleep-deprived members of society.

In this study, the later a teenager started school, the later he or she woke up, with average wake-up times having been just after 6:00 a.m. for those starting school between 7:00 and 7:30 a.m. and about 7:00 a.m. for those starting school after 8:30 a.m. But only those teens who started after 8:30 a.m. achieved the 8-hour recommended sleep duration, said Nicole Nahmod, during a presentation at the annual meeting of the Associated Professional Sleep Societies.

The students with the later school start times averaged 32 minutes of extra sleep, when compared with their early-rising colleagues, noted Ms. Nahmod, who is one of the study’s authors, a research technician, and study coordinator at Pennsylvania State University, Hershey. Specifically, adolescents who started school after 8:30 a.m. had a mean sleep duration of 8.1 hours, while those who started school earlier slept for only 7.5 hours a night.*

*This article was updated on June 6, 2017.

Recent guidelines from the United States Preventive Services Task Force (USPSTF) say that there is insufficient evidence to recommend screening for obstructive sleep apnea in people who have no symptoms of it.^1–3

The USPSTF committee systematically reviewed the evidence, sifting through 1,315 articles,³ and found no randomized controlled trials that compared screening with no screening in adults who have no symptoms (or no recognized symptoms) of obstructive sleep apnea. Conclusion: “The current evidence is insufficient to assess the balance of benefits and harms of screening for [obstructive sleep apnea] in asymptomatic adults.”¹

This is logical, rigorous, and evidence-based. However, the conclusions might be misinterpreted and need to be put into context.

SCREENING IS WARRANTED IF PATIENTS HAVE SYMPTOMS

First, note that the USPSTF is referring to people who have no symptoms. The American Academy of Sleep Medicine has issued recommendations about screening and diagnostic testing in people who do have symptoms,⁴ in whom it is important to pursue screening and diagnostic testing.

Symptoms of obstructive sleep apnea include excessive daytime sleepiness, fatigue, drowsy driving, disrupted or fragmented sleep, nocturia, witnessed apnea, snoring, restless sleep, neurocognitive deficits, and depressed mood. Treating it improves these symptoms, as clinical trials have shown unequivocally and consistently.⁵

Moreover, the third edition of the International Classification of Sleep Disorders defines obstructive sleep apnea as an obstructive apnea-hypopnea index of 15 or more events per hour even in the absence of symptoms. This threshold recognizes the risk of adverse health outcomes observed in population-based studies (ie, in participants recruited irrespective of symptoms).⁶

ABSENCE OF EVIDENCE, NOT EVIDENCE OF ABSENCE

Second, the absence of sufficient evidence cited by the USPSTF does not necessarily mean that screening for obstructive sleep apnea in asymptomatic people is not beneficial—it has just not been systematically studied. There was insufficient evidence available to make a recommendation to allocate resources to screen all patients irrespective of symptoms.

The Sleep Heart Health Study suggested that few people with obstructive sleep apnea were diagnosed with it and that even fewer were treated for it.⁷ More recent data indicate that this underdiagnosis persists and is more pervasive in underserved minority groups.^8,9

SCREENING VS CASE-FINDING

Moreover, screening is not the same as case-finding. The purpose of screening, as defined 50 years ago by Wilson and Jungner in a report for the World Health Organization, is “to discover those among the apparently well who are in fact suffering from disease.”¹⁰

Case-finding, on the other hand, focuses on those suspected of being at risk of the disease. In the case of obstructive sleep apnea, this is a lot of people. The overall prevalence of obstructive sleep apnea is about 26% by one estimate,¹¹ and many more people have risk factors for it. For example, in one study, 69% of patients presenting to a primary care clinic were overweight or obese,¹² and many primary care patients have diseases that obstructive sleep apnea can exacerbate. One can therefore argue that in clinical practice, testing for obstructive sleep apnea is more like case-finding than screening—most patients that you see have unrecognized symptoms of it or risk factors for it.

Principles for screening outlined by Wilson and Jungner¹⁰ were:

• The condition we are trying to detect should be important
• There should be an accepted treatment for it
• Facilities for diagnosis and treatment should be available
• Testing should be acceptable to the population
• There should be cost benefit to the expense of case-finding
• There should be an agreed-upon policy on whom to treat as patients.

Screening for obstructive sleep apnea meets many of these criteria.

Obstructive sleep apnea is important

Solid evidence exists that obstructive sleep apnea exerts a bad effect on health and quality of life. Population-based studies that enrolled participants irrespective of symptoms indicate that the risk of death is about twice as high in those with severe obstructive sleep apnea as in those without, and treatment exerts benefit especially in those with cardiovascular risk.^13,14 Therefore, the criterion for screening that says the disease must be important is met.

Pathophysiologic pathways by which obstructive sleep apnea causes harm include intermittent hypoxia, hypercapnia, intrathoracic pressure swings, and autonomic nervous system fluctuations. 

Treatment is beneficial

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recognized obstructive sleep apnea as a cause of hypertension.¹⁵

Treating obstructive sleep apnea lowers blood pressure, which in turn improves cardio­vascular outcomes. Effects are most pronounced in those with resistant hypertension. The reduction in blood pressure is only about 2 to 3 mm Hg, but this translates to a 4% to 8% reduction in future risk of stroke and coronary heart disease.^16,17

The Continuous Positive Airway Pressure Treatment of Obstructive Sleep Apnea to Prevent Cardiovascular Disease multicenter randomized clinical trial investigated the impact of treating obstructive sleep apnea with continuous positive airway pressure (CPAP) compared with usual care.¹⁸ Although no statistically significant difference was seen in the composite cardiovascular outcome, propensity-score analysis in the subgroup adherent to CPAP demonstrated a lower composite of cerebral events in those who used CPAP for at least 4 hours a day.

The findings from this trial are difficult to interpret for several reasons. Adherence to CPAP was suboptimal, the severity of obstructive sleep apnea might not have been bad enough to permit observation of a significant treatment effect, and the generalizability of the findings is unclear, given that many of the participants were from underresourced regions.¹⁹

In a meta-analysis of cohort studies comprising more than 3 million participants, Fu et al found that the cardiovascular mortality rate was 63% lower in those with obstructive sleep apnea using CPAP than in untreated patients.²⁰

APPLY CLINICAL JUDGMENT

Overall, the USPSTF report is intended to guide healthcare decision-makers. However, it includes a caveat to not substitute the findings for clinical judgment and to interpret the findings in the context of collateral pertinent information.²

Although no high-quality data exist to support or refute global screening for obstructive sleep apnea in the primary care setting, the high prevalence of this disease and its detrimental effects on health and quality of life if left untreated should not be dismissed.

Arguably, most patients who present to primary care clinics are not healthy, are not free of symptoms, and are at risk of obstructive sleep apnea because they are obese. Testing for it is therefore more like case-finding than screening.

In view of the serious consequences of obstructive sleep apnea, we should view the situation as an opportunity to examine the impact of screening. Perhaps using electronic medical records, we could collect sleep-specific measures, implement case-finding strategies, and perform pragmatic clinical trials to inform and guide optimal and cost-effective screening approaches.

Patients with common disorders such as obstructive sleep apnea are often considered asymptomatic until asked about symptoms. Therefore, careful review of systems incorporating sleep health is important, particularly as patients do not typically volunteer this information. Obtaining this history does not necessarily fall under the USPSTF’s recommendation not to screen.

Future efforts should focus on leveraging the electronic medical record platform to collect sleep-specific measures, implementing case-finding strategies, and performing pragmatic clinical trials in the primary care setting to inform and guide optimal and cost-effective approaches to screening.

Recent guidelines from the United States Preventive Services Task Force (USPSTF) say that there is insufficient evidence to recommend screening for obstructive sleep apnea in people who have no symptoms of it.^1–3

The USPSTF committee systematically reviewed the evidence, sifting through 1,315 articles,³ and found no randomized controlled trials that compared screening with no screening in adults who have no symptoms (or no recognized symptoms) of obstructive sleep apnea. Conclusion: “The current evidence is insufficient to assess the balance of benefits and harms of screening for [obstructive sleep apnea] in asymptomatic adults.”¹

This is logical, rigorous, and evidence-based. However, the conclusions might be misinterpreted and need to be put into context.

SCREENING IS WARRANTED IF PATIENTS HAVE SYMPTOMS

First, note that the USPSTF is referring to people who have no symptoms. The American Academy of Sleep Medicine has issued recommendations about screening and diagnostic testing in people who do have symptoms,⁴ in whom it is important to pursue screening and diagnostic testing.

Symptoms of obstructive sleep apnea include excessive daytime sleepiness, fatigue, drowsy driving, disrupted or fragmented sleep, nocturia, witnessed apnea, snoring, restless sleep, neurocognitive deficits, and depressed mood. Treating it improves these symptoms, as clinical trials have shown unequivocally and consistently.⁵

Moreover, the third edition of the International Classification of Sleep Disorders defines obstructive sleep apnea as an obstructive apnea-hypopnea index of 15 or more events per hour even in the absence of symptoms. This threshold recognizes the risk of adverse health outcomes observed in population-based studies (ie, in participants recruited irrespective of symptoms).⁶

ABSENCE OF EVIDENCE, NOT EVIDENCE OF ABSENCE

Second, the absence of sufficient evidence cited by the USPSTF does not necessarily mean that screening for obstructive sleep apnea in asymptomatic people is not beneficial—it has just not been systematically studied. There was insufficient evidence available to make a recommendation to allocate resources to screen all patients irrespective of symptoms.

The Sleep Heart Health Study suggested that few people with obstructive sleep apnea were diagnosed with it and that even fewer were treated for it.⁷ More recent data indicate that this underdiagnosis persists and is more pervasive in underserved minority groups.^8,9

SCREENING VS CASE-FINDING

Moreover, screening is not the same as case-finding. The purpose of screening, as defined 50 years ago by Wilson and Jungner in a report for the World Health Organization, is “to discover those among the apparently well who are in fact suffering from disease.”¹⁰

Case-finding, on the other hand, focuses on those suspected of being at risk of the disease. In the case of obstructive sleep apnea, this is a lot of people. The overall prevalence of obstructive sleep apnea is about 26% by one estimate,¹¹ and many more people have risk factors for it. For example, in one study, 69% of patients presenting to a primary care clinic were overweight or obese,¹² and many primary care patients have diseases that obstructive sleep apnea can exacerbate. One can therefore argue that in clinical practice, testing for obstructive sleep apnea is more like case-finding than screening—most patients that you see have unrecognized symptoms of it or risk factors for it.

Principles for screening outlined by Wilson and Jungner¹⁰ were:

• The condition we are trying to detect should be important
• There should be an accepted treatment for it
• Facilities for diagnosis and treatment should be available
• Testing should be acceptable to the population
• There should be cost benefit to the expense of case-finding
• There should be an agreed-upon policy on whom to treat as patients.

Screening for obstructive sleep apnea meets many of these criteria.

Obstructive sleep apnea is important

Solid evidence exists that obstructive sleep apnea exerts a bad effect on health and quality of life. Population-based studies that enrolled participants irrespective of symptoms indicate that the risk of death is about twice as high in those with severe obstructive sleep apnea as in those without, and treatment exerts benefit especially in those with cardiovascular risk.^13,14 Therefore, the criterion for screening that says the disease must be important is met.

Pathophysiologic pathways by which obstructive sleep apnea causes harm include intermittent hypoxia, hypercapnia, intrathoracic pressure swings, and autonomic nervous system fluctuations. 

Treatment is beneficial

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recognized obstructive sleep apnea as a cause of hypertension.¹⁵

Treating obstructive sleep apnea lowers blood pressure, which in turn improves cardio­vascular outcomes. Effects are most pronounced in those with resistant hypertension. The reduction in blood pressure is only about 2 to 3 mm Hg, but this translates to a 4% to 8% reduction in future risk of stroke and coronary heart disease.^16,17

The Continuous Positive Airway Pressure Treatment of Obstructive Sleep Apnea to Prevent Cardiovascular Disease multicenter randomized clinical trial investigated the impact of treating obstructive sleep apnea with continuous positive airway pressure (CPAP) compared with usual care.¹⁸ Although no statistically significant difference was seen in the composite cardiovascular outcome, propensity-score analysis in the subgroup adherent to CPAP demonstrated a lower composite of cerebral events in those who used CPAP for at least 4 hours a day.

The findings from this trial are difficult to interpret for several reasons. Adherence to CPAP was suboptimal, the severity of obstructive sleep apnea might not have been bad enough to permit observation of a significant treatment effect, and the generalizability of the findings is unclear, given that many of the participants were from underresourced regions.¹⁹

In a meta-analysis of cohort studies comprising more than 3 million participants, Fu et al found that the cardiovascular mortality rate was 63% lower in those with obstructive sleep apnea using CPAP than in untreated patients.²⁰

APPLY CLINICAL JUDGMENT

Overall, the USPSTF report is intended to guide healthcare decision-makers. However, it includes a caveat to not substitute the findings for clinical judgment and to interpret the findings in the context of collateral pertinent information.²

Although no high-quality data exist to support or refute global screening for obstructive sleep apnea in the primary care setting, the high prevalence of this disease and its detrimental effects on health and quality of life if left untreated should not be dismissed.

Arguably, most patients who present to primary care clinics are not healthy, are not free of symptoms, and are at risk of obstructive sleep apnea because they are obese. Testing for it is therefore more like case-finding than screening.

In view of the serious consequences of obstructive sleep apnea, we should view the situation as an opportunity to examine the impact of screening. Perhaps using electronic medical records, we could collect sleep-specific measures, implement case-finding strategies, and perform pragmatic clinical trials to inform and guide optimal and cost-effective screening approaches.

Patients with common disorders such as obstructive sleep apnea are often considered asymptomatic until asked about symptoms. Therefore, careful review of systems incorporating sleep health is important, particularly as patients do not typically volunteer this information. Obtaining this history does not necessarily fall under the USPSTF’s recommendation not to screen.

Future efforts should focus on leveraging the electronic medical record platform to collect sleep-specific measures, implementing case-finding strategies, and performing pragmatic clinical trials in the primary care setting to inform and guide optimal and cost-effective approaches to screening.

Recent guidelines from the United States Preventive Services Task Force (USPSTF) say that there is insufficient evidence to recommend screening for obstructive sleep apnea in people who have no symptoms of it.^1–3

The USPSTF committee systematically reviewed the evidence, sifting through 1,315 articles,³ and found no randomized controlled trials that compared screening with no screening in adults who have no symptoms (or no recognized symptoms) of obstructive sleep apnea. Conclusion: “The current evidence is insufficient to assess the balance of benefits and harms of screening for [obstructive sleep apnea] in asymptomatic adults.”¹

This is logical, rigorous, and evidence-based. However, the conclusions might be misinterpreted and need to be put into context.

SCREENING IS WARRANTED IF PATIENTS HAVE SYMPTOMS

First, note that the USPSTF is referring to people who have no symptoms. The American Academy of Sleep Medicine has issued recommendations about screening and diagnostic testing in people who do have symptoms,⁴ in whom it is important to pursue screening and diagnostic testing.

Symptoms of obstructive sleep apnea include excessive daytime sleepiness, fatigue, drowsy driving, disrupted or fragmented sleep, nocturia, witnessed apnea, snoring, restless sleep, neurocognitive deficits, and depressed mood. Treating it improves these symptoms, as clinical trials have shown unequivocally and consistently.⁵

Moreover, the third edition of the International Classification of Sleep Disorders defines obstructive sleep apnea as an obstructive apnea-hypopnea index of 15 or more events per hour even in the absence of symptoms. This threshold recognizes the risk of adverse health outcomes observed in population-based studies (ie, in participants recruited irrespective of symptoms).⁶

ABSENCE OF EVIDENCE, NOT EVIDENCE OF ABSENCE

Second, the absence of sufficient evidence cited by the USPSTF does not necessarily mean that screening for obstructive sleep apnea in asymptomatic people is not beneficial—it has just not been systematically studied. There was insufficient evidence available to make a recommendation to allocate resources to screen all patients irrespective of symptoms.

The Sleep Heart Health Study suggested that few people with obstructive sleep apnea were diagnosed with it and that even fewer were treated for it.⁷ More recent data indicate that this underdiagnosis persists and is more pervasive in underserved minority groups.^8,9

SCREENING VS CASE-FINDING

Moreover, screening is not the same as case-finding. The purpose of screening, as defined 50 years ago by Wilson and Jungner in a report for the World Health Organization, is “to discover those among the apparently well who are in fact suffering from disease.”¹⁰

Case-finding, on the other hand, focuses on those suspected of being at risk of the disease. In the case of obstructive sleep apnea, this is a lot of people. The overall prevalence of obstructive sleep apnea is about 26% by one estimate,¹¹ and many more people have risk factors for it. For example, in one study, 69% of patients presenting to a primary care clinic were overweight or obese,¹² and many primary care patients have diseases that obstructive sleep apnea can exacerbate. One can therefore argue that in clinical practice, testing for obstructive sleep apnea is more like case-finding than screening—most patients that you see have unrecognized symptoms of it or risk factors for it.

Principles for screening outlined by Wilson and Jungner¹⁰ were:

• The condition we are trying to detect should be important
• There should be an accepted treatment for it
• Facilities for diagnosis and treatment should be available
• Testing should be acceptable to the population
• There should be cost benefit to the expense of case-finding
• There should be an agreed-upon policy on whom to treat as patients.

Screening for obstructive sleep apnea meets many of these criteria.

Obstructive sleep apnea is important

Solid evidence exists that obstructive sleep apnea exerts a bad effect on health and quality of life. Population-based studies that enrolled participants irrespective of symptoms indicate that the risk of death is about twice as high in those with severe obstructive sleep apnea as in those without, and treatment exerts benefit especially in those with cardiovascular risk.^13,14 Therefore, the criterion for screening that says the disease must be important is met.

Pathophysiologic pathways by which obstructive sleep apnea causes harm include intermittent hypoxia, hypercapnia, intrathoracic pressure swings, and autonomic nervous system fluctuations. 

Treatment is beneficial

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recognized obstructive sleep apnea as a cause of hypertension.¹⁵

Treating obstructive sleep apnea lowers blood pressure, which in turn improves cardio­vascular outcomes. Effects are most pronounced in those with resistant hypertension. The reduction in blood pressure is only about 2 to 3 mm Hg, but this translates to a 4% to 8% reduction in future risk of stroke and coronary heart disease.^16,17

The Continuous Positive Airway Pressure Treatment of Obstructive Sleep Apnea to Prevent Cardiovascular Disease multicenter randomized clinical trial investigated the impact of treating obstructive sleep apnea with continuous positive airway pressure (CPAP) compared with usual care.¹⁸ Although no statistically significant difference was seen in the composite cardiovascular outcome, propensity-score analysis in the subgroup adherent to CPAP demonstrated a lower composite of cerebral events in those who used CPAP for at least 4 hours a day.

The findings from this trial are difficult to interpret for several reasons. Adherence to CPAP was suboptimal, the severity of obstructive sleep apnea might not have been bad enough to permit observation of a significant treatment effect, and the generalizability of the findings is unclear, given that many of the participants were from underresourced regions.¹⁹

In a meta-analysis of cohort studies comprising more than 3 million participants, Fu et al found that the cardiovascular mortality rate was 63% lower in those with obstructive sleep apnea using CPAP than in untreated patients.²⁰

APPLY CLINICAL JUDGMENT

Overall, the USPSTF report is intended to guide healthcare decision-makers. However, it includes a caveat to not substitute the findings for clinical judgment and to interpret the findings in the context of collateral pertinent information.²

Although no high-quality data exist to support or refute global screening for obstructive sleep apnea in the primary care setting, the high prevalence of this disease and its detrimental effects on health and quality of life if left untreated should not be dismissed.

Arguably, most patients who present to primary care clinics are not healthy, are not free of symptoms, and are at risk of obstructive sleep apnea because they are obese. Testing for it is therefore more like case-finding than screening.

In view of the serious consequences of obstructive sleep apnea, we should view the situation as an opportunity to examine the impact of screening. Perhaps using electronic medical records, we could collect sleep-specific measures, implement case-finding strategies, and perform pragmatic clinical trials to inform and guide optimal and cost-effective screening approaches.

Patients with common disorders such as obstructive sleep apnea are often considered asymptomatic until asked about symptoms. Therefore, careful review of systems incorporating sleep health is important, particularly as patients do not typically volunteer this information. Obtaining this history does not necessarily fall under the USPSTF’s recommendation not to screen.

Future efforts should focus on leveraging the electronic medical record platform to collect sleep-specific measures, implementing case-finding strategies, and performing pragmatic clinical trials in the primary care setting to inform and guide optimal and cost-effective approaches to screening.

More and more consumers are using wearable devices and smartphones to monitor and measure various body functions, including sleep. Many patients now present their providers with sleep data obtained from their phones and other devices. But can these devices provide valid, useful clinical information?

This article describes common sleep tracking devices available to consumers and the mechanisms the devices probably use to distinguish sleep from wakefulness (their algorithms are secret), the studies evaluating the validity of device manufacturers’ claims, and their clinical utility and limitations.

DEVICES ARE COMMON

Close to 1 in 10 adults over age 18 owns an activity tracker, and sales are projected to reach $50 billion by 2018.¹ Even more impressive, close to 69% of Americans own a smartphone,¹ and more than half use it as an alarm clock.²

At the same time that these devices have become so popular, sleep medicine has come of age, and experts have been pushing to improve people’s sleep and increase awareness of sleep disorders.^3,4 While the technology has significantly advanced, adoption of data from these devices for clinical evaluation has been limited. Studies examining the validity of these devices have only recently been conducted, and companies that make the devices have not been forthcoming with details of the specific algorithms they use to tell if the patient is asleep or awake or what stage of sleep the patient is in.

WHAT ARE THESE DEVICES?

Consumer tracking devices that claim to measure sleep are easily available for purchase and include wearable fitness trackers such as Fitbit, Jawbone UP, and Nike+ Fuelband. Other sleep tracking devices are catalogued by Ko et al.⁵ Various smartphone applications (apps) are also available.

Fitness trackers, usually worn as a wrist band, are primarily designed to measure movement and activity, but manufacturers now claim the trackers can also measure sleep. Collected data are available for the user to review the following day. In most cases, these trackers display sleep and wake times; others also claim to record sound sleep, light sleep, and the number and duration of awakenings. Most fitness trackers have complementary apps available for download that graphically display the data on smartphones and interact with social media to allow users to post their sleep and activity data.

More than 500 sleep-related apps are available for download to smartphones in the iTunes app store⁵; the Sleep Cycle alarm clock app was among the top 5 sleep-tracking apps downloaded in 2014.⁶ Because sleep data collection relies on the smartphone being placed on the user’s mattress, movements of bed partners, pets, and bedding may interfere with results. In most cases, the apps display data in a format similar to that of fitness trackers. Some claim to determine the optimal sleep phase for the alarm to wake the user.

HOW DOES THE TECHNOLOGY WORK?

Older activity-tracking devices used single-channel electroencephalographic recordings or multiple physiologic channels such as galvanic skin response, skin temperature, and heat flux to measure activity to determine transitions between periods of sleep and wakefulness.^7,8

None of the currently available consumer sleep tracking devices discloses the exact mechanisms used to measure sleep and wakefulness, but most appear to rely on 3-axis accelerometers,⁹ ie, microelectromechanical devices that measure front-to-back, side-to-side, and up-and-down motion and convert the data into an activity count. Activity counts are acquired over 30- or 60-second intervals and are entered into algorithms that determine if the pattern indicates that the patient is awake or asleep. This is the same method that actigraphy uses to evaluate sleep, but most actigraphs used in medicine disclose their mechanisms and provide clinicians with the option of using various validated algorithms to classify the activity counts into sleep or awake periods.^9–11

ARE THE MEASURES VALID?

Only a few studies have examined the validity and accuracy of current fitness trackers and apps for measuring sleep.

The available studies are difficult to compare; most have been small and used different actigraphy devices for comparison. Some tested healthy volunteers, others included people with suspected or confirmed sleep disorders, and some had both types of participants. In many studies, the device was compared with polysomnography for only 1 night, making the “first-night effect” likely to be a confounding factor, as people tend to sleep worse during the first night of testing. Technical failures for the devices were noted in some studies.¹² In addition, some currently used apps may use different platforms than the devices used in these studies, limiting the extrapolation of results.

As with fitness trackers, few studies have been done to examine the validity of smartphone apps.⁵ Findings of 3 studies are summarized in Table 2.^17–19 In addition to tracking the duration and depth of sleep, some apps purport to detect snoring, sleep apnea, and periodic limb movements of sleep. Discussion of these apps is beyond the scope of this review.

ARE THE DEVICES CLINICALLY USEFUL?

Although a thorough history remains the cornerstone of a good evaluation of sleep problems, testing is sometimes essential, and in certain situations, objective data can complement the history and clarify the diagnosis.

Polysomnography remains the gold standard for telling when the patient is asleep vs awake, diagnosing sleep-disordered breathing, detecting periodic limb movements and parasomnias, and aiding in the diagnosis of narcolepsy.

Actigraphy, which uses technology similar to fitness trackers, can help distinguish sleep from wakefulness, reveal erratic sleep schedules, and help diagnose circadian rhythm sleep disorders. In patients with insomnia, actigraphy can help determine daily sleep patterns and response to treatment.²⁰ It can be especially useful for patients who cannot provide a clear history, eg, children and those with developmental disabilities or cognitive dysfunction.

Consumer sleep tracking devices, like actigraphy, are portable and unobtrusive, providing a way to measure sleep duration and demonstrate sleep patterns in a patient’s natural environment. Being more accessible, cheaper, and less time-consuming than clinical tests, the commercially available devices could be clinically useful in some situations, eg, for monitoring overall sleep patterns to look for circadian sleep-wake disorders, commonly seen in shift workers (shift work disorder) or adolescents (delayed sleep-wake phase disorder); or in patients with poor motivation to maintain a sleep diary. Because of their poor performance in clinical trials, they should not be relied upon to distinguish sleep from wakefulness, quantify the amount of sleep, determine sleep stages, and awaken patients exclusively from light sleep.

Discerning poor sleep hygiene from insomnia

Patients with insomnia tend to take longer to go to sleep (have longer sleep latencies), wake up more (have more disturbed sleep with increased awakenings), and have shorter sleep times with reduced sleep efficiencies.²¹ Sleep tracking devices tend to be less accurate for patients with short sleep duration and disturbed sleep, limiting their usefulness in this group. Furthermore, patients with insomnia tend to underestimate their sleep time and overestimate sleep latency; some devices also tend to overestimate the time to fall asleep, reinforcing this common error made by patients.^22,23

On the other hand, data from sleep tracking devices could help distinguish poor sleep hygiene from an insomnia disorder. For example, the data may indicate that a patient has poor sleep habits, such as taking long daytime naps or having significantly variable time in and out of bed from day to day. The total times asleep and awake in the middle of the night may also be substantially different on each night, which would also possibly indicate poor sleep hygiene.

Detecting circadian rhythms

A device may show that a patient has a clear circadian preference that is not in line with his or her daily routines, suggesting an underlying circadian rhythm sleep-wake disorder. This may be evident by bedtimes and wake times that are consistent but substantially out of sync with one’s social or occupational needs.

Measuring overall sleep duration

In people with normal sleep, fitness trackers perform reasonably well for measuring overall sleep duration. This information could be used to assess a patient with daytime sleepiness and fatigue to evaluate insufficient sleep as an etiologic factor.

Table 3 summarizes how to evaluate the data from sleep apps and fitness tracking devices for clinical use. While these features of consumer sleep tracking devices could conceivably help in the above clinical scenarios, further validation of devices in clinical populations is necessary before their use can be recommended without reservation.

ADVISING PATIENTS

Patients sometimes present to clinicians with concerns about the duration of sleep time and time spent in various sleep stages as delineated by their sleep tracking devices. Currently, these devices do not appear to be able to adequately distinguish various sleep stages, and in many users, they can substantially underestimate or overestimate sleep parameters such as time taken to fall asleep or duration of awakenings in the middle of the night. Patients can be reassured about this lack of evidence and should be advised to not place too much weight on such data alone.

Sleep “goals” set by many devices have not been scientifically validated. People without sleep problems should be discouraged from making substantial changes to their routines to accommodate sleep targets set by the devices. Patients should be counseled about the pitfalls of the data and can be reassured that little evidence suggests that time spent in various sleep stages correlates with adverse daytime consequences or with poor health outcomes.

Some of the apps used as alarm clocks claim to be able to tell what stage of sleep people are in and wait to awaken them until they are in a light stage, which is less jarring than being awakened from a deep stage, but the evidence for this is unclear. In the one study that tested this claim, the app did not awaken participants from light sleep more often than is likely to occur by chance.¹⁷ The utility of these apps as personalized alarm clocks is still extremely limited, and patients should be counseled to obtain an adequate amount of sleep rather than rely on devices to awaken them during specific sleep stages.

The rates for discontinuing the use of these devices are high, which could limit their utility. Some surveys have shown that close to 50% of users stop using fitness trackers; 33% stop using them within 6 months of obtaining the device.²⁴ Also, there is little evidence that close monitoring of sleep results in behavior changes or improved sleep duration. Conversely, the potential harms of excessive monitoring of one’s sleep are currently unknown.

More and more consumers are using wearable devices and smartphones to monitor and measure various body functions, including sleep. Many patients now present their providers with sleep data obtained from their phones and other devices. But can these devices provide valid, useful clinical information?

This article describes common sleep tracking devices available to consumers and the mechanisms the devices probably use to distinguish sleep from wakefulness (their algorithms are secret), the studies evaluating the validity of device manufacturers’ claims, and their clinical utility and limitations.

DEVICES ARE COMMON

Close to 1 in 10 adults over age 18 owns an activity tracker, and sales are projected to reach $50 billion by 2018.¹ Even more impressive, close to 69% of Americans own a smartphone,¹ and more than half use it as an alarm clock.²

At the same time that these devices have become so popular, sleep medicine has come of age, and experts have been pushing to improve people’s sleep and increase awareness of sleep disorders.^3,4 While the technology has significantly advanced, adoption of data from these devices for clinical evaluation has been limited. Studies examining the validity of these devices have only recently been conducted, and companies that make the devices have not been forthcoming with details of the specific algorithms they use to tell if the patient is asleep or awake or what stage of sleep the patient is in.

WHAT ARE THESE DEVICES?

Consumer tracking devices that claim to measure sleep are easily available for purchase and include wearable fitness trackers such as Fitbit, Jawbone UP, and Nike+ Fuelband. Other sleep tracking devices are catalogued by Ko et al.⁵ Various smartphone applications (apps) are also available.

Fitness trackers, usually worn as a wrist band, are primarily designed to measure movement and activity, but manufacturers now claim the trackers can also measure sleep. Collected data are available for the user to review the following day. In most cases, these trackers display sleep and wake times; others also claim to record sound sleep, light sleep, and the number and duration of awakenings. Most fitness trackers have complementary apps available for download that graphically display the data on smartphones and interact with social media to allow users to post their sleep and activity data.

More than 500 sleep-related apps are available for download to smartphones in the iTunes app store⁵; the Sleep Cycle alarm clock app was among the top 5 sleep-tracking apps downloaded in 2014.⁶ Because sleep data collection relies on the smartphone being placed on the user’s mattress, movements of bed partners, pets, and bedding may interfere with results. In most cases, the apps display data in a format similar to that of fitness trackers. Some claim to determine the optimal sleep phase for the alarm to wake the user.

HOW DOES THE TECHNOLOGY WORK?

Older activity-tracking devices used single-channel electroencephalographic recordings or multiple physiologic channels such as galvanic skin response, skin temperature, and heat flux to measure activity to determine transitions between periods of sleep and wakefulness.^7,8

None of the currently available consumer sleep tracking devices discloses the exact mechanisms used to measure sleep and wakefulness, but most appear to rely on 3-axis accelerometers,⁹ ie, microelectromechanical devices that measure front-to-back, side-to-side, and up-and-down motion and convert the data into an activity count. Activity counts are acquired over 30- or 60-second intervals and are entered into algorithms that determine if the pattern indicates that the patient is awake or asleep. This is the same method that actigraphy uses to evaluate sleep, but most actigraphs used in medicine disclose their mechanisms and provide clinicians with the option of using various validated algorithms to classify the activity counts into sleep or awake periods.^9–11

ARE THE MEASURES VALID?

Only a few studies have examined the validity and accuracy of current fitness trackers and apps for measuring sleep.

The available studies are difficult to compare; most have been small and used different actigraphy devices for comparison. Some tested healthy volunteers, others included people with suspected or confirmed sleep disorders, and some had both types of participants. In many studies, the device was compared with polysomnography for only 1 night, making the “first-night effect” likely to be a confounding factor, as people tend to sleep worse during the first night of testing. Technical failures for the devices were noted in some studies.¹² In addition, some currently used apps may use different platforms than the devices used in these studies, limiting the extrapolation of results.

As with fitness trackers, few studies have been done to examine the validity of smartphone apps.⁵ Findings of 3 studies are summarized in Table 2.^17–19 In addition to tracking the duration and depth of sleep, some apps purport to detect snoring, sleep apnea, and periodic limb movements of sleep. Discussion of these apps is beyond the scope of this review.

ARE THE DEVICES CLINICALLY USEFUL?

Although a thorough history remains the cornerstone of a good evaluation of sleep problems, testing is sometimes essential, and in certain situations, objective data can complement the history and clarify the diagnosis.

Polysomnography remains the gold standard for telling when the patient is asleep vs awake, diagnosing sleep-disordered breathing, detecting periodic limb movements and parasomnias, and aiding in the diagnosis of narcolepsy.

Actigraphy, which uses technology similar to fitness trackers, can help distinguish sleep from wakefulness, reveal erratic sleep schedules, and help diagnose circadian rhythm sleep disorders. In patients with insomnia, actigraphy can help determine daily sleep patterns and response to treatment.²⁰ It can be especially useful for patients who cannot provide a clear history, eg, children and those with developmental disabilities or cognitive dysfunction.

Consumer sleep tracking devices, like actigraphy, are portable and unobtrusive, providing a way to measure sleep duration and demonstrate sleep patterns in a patient’s natural environment. Being more accessible, cheaper, and less time-consuming than clinical tests, the commercially available devices could be clinically useful in some situations, eg, for monitoring overall sleep patterns to look for circadian sleep-wake disorders, commonly seen in shift workers (shift work disorder) or adolescents (delayed sleep-wake phase disorder); or in patients with poor motivation to maintain a sleep diary. Because of their poor performance in clinical trials, they should not be relied upon to distinguish sleep from wakefulness, quantify the amount of sleep, determine sleep stages, and awaken patients exclusively from light sleep.

Discerning poor sleep hygiene from insomnia

Patients with insomnia tend to take longer to go to sleep (have longer sleep latencies), wake up more (have more disturbed sleep with increased awakenings), and have shorter sleep times with reduced sleep efficiencies.²¹ Sleep tracking devices tend to be less accurate for patients with short sleep duration and disturbed sleep, limiting their usefulness in this group. Furthermore, patients with insomnia tend to underestimate their sleep time and overestimate sleep latency; some devices also tend to overestimate the time to fall asleep, reinforcing this common error made by patients.^22,23

On the other hand, data from sleep tracking devices could help distinguish poor sleep hygiene from an insomnia disorder. For example, the data may indicate that a patient has poor sleep habits, such as taking long daytime naps or having significantly variable time in and out of bed from day to day. The total times asleep and awake in the middle of the night may also be substantially different on each night, which would also possibly indicate poor sleep hygiene.

Detecting circadian rhythms

A device may show that a patient has a clear circadian preference that is not in line with his or her daily routines, suggesting an underlying circadian rhythm sleep-wake disorder. This may be evident by bedtimes and wake times that are consistent but substantially out of sync with one’s social or occupational needs.

Measuring overall sleep duration

In people with normal sleep, fitness trackers perform reasonably well for measuring overall sleep duration. This information could be used to assess a patient with daytime sleepiness and fatigue to evaluate insufficient sleep as an etiologic factor.

Table 3 summarizes how to evaluate the data from sleep apps and fitness tracking devices for clinical use. While these features of consumer sleep tracking devices could conceivably help in the above clinical scenarios, further validation of devices in clinical populations is necessary before their use can be recommended without reservation.

ADVISING PATIENTS

Patients sometimes present to clinicians with concerns about the duration of sleep time and time spent in various sleep stages as delineated by their sleep tracking devices. Currently, these devices do not appear to be able to adequately distinguish various sleep stages, and in many users, they can substantially underestimate or overestimate sleep parameters such as time taken to fall asleep or duration of awakenings in the middle of the night. Patients can be reassured about this lack of evidence and should be advised to not place too much weight on such data alone.

Sleep “goals” set by many devices have not been scientifically validated. People without sleep problems should be discouraged from making substantial changes to their routines to accommodate sleep targets set by the devices. Patients should be counseled about the pitfalls of the data and can be reassured that little evidence suggests that time spent in various sleep stages correlates with adverse daytime consequences or with poor health outcomes.

Some of the apps used as alarm clocks claim to be able to tell what stage of sleep people are in and wait to awaken them until they are in a light stage, which is less jarring than being awakened from a deep stage, but the evidence for this is unclear. In the one study that tested this claim, the app did not awaken participants from light sleep more often than is likely to occur by chance.¹⁷ The utility of these apps as personalized alarm clocks is still extremely limited, and patients should be counseled to obtain an adequate amount of sleep rather than rely on devices to awaken them during specific sleep stages.

The rates for discontinuing the use of these devices are high, which could limit their utility. Some surveys have shown that close to 50% of users stop using fitness trackers; 33% stop using them within 6 months of obtaining the device.²⁴ Also, there is little evidence that close monitoring of sleep results in behavior changes or improved sleep duration. Conversely, the potential harms of excessive monitoring of one’s sleep are currently unknown.

More and more consumers are using wearable devices and smartphones to monitor and measure various body functions, including sleep. Many patients now present their providers with sleep data obtained from their phones and other devices. But can these devices provide valid, useful clinical information?

This article describes common sleep tracking devices available to consumers and the mechanisms the devices probably use to distinguish sleep from wakefulness (their algorithms are secret), the studies evaluating the validity of device manufacturers’ claims, and their clinical utility and limitations.

DEVICES ARE COMMON

Close to 1 in 10 adults over age 18 owns an activity tracker, and sales are projected to reach $50 billion by 2018.¹ Even more impressive, close to 69% of Americans own a smartphone,¹ and more than half use it as an alarm clock.²

At the same time that these devices have become so popular, sleep medicine has come of age, and experts have been pushing to improve people’s sleep and increase awareness of sleep disorders.^3,4 While the technology has significantly advanced, adoption of data from these devices for clinical evaluation has been limited. Studies examining the validity of these devices have only recently been conducted, and companies that make the devices have not been forthcoming with details of the specific algorithms they use to tell if the patient is asleep or awake or what stage of sleep the patient is in.

WHAT ARE THESE DEVICES?

Consumer tracking devices that claim to measure sleep are easily available for purchase and include wearable fitness trackers such as Fitbit, Jawbone UP, and Nike+ Fuelband. Other sleep tracking devices are catalogued by Ko et al.⁵ Various smartphone applications (apps) are also available.

Fitness trackers, usually worn as a wrist band, are primarily designed to measure movement and activity, but manufacturers now claim the trackers can also measure sleep. Collected data are available for the user to review the following day. In most cases, these trackers display sleep and wake times; others also claim to record sound sleep, light sleep, and the number and duration of awakenings. Most fitness trackers have complementary apps available for download that graphically display the data on smartphones and interact with social media to allow users to post their sleep and activity data.

More than 500 sleep-related apps are available for download to smartphones in the iTunes app store⁵; the Sleep Cycle alarm clock app was among the top 5 sleep-tracking apps downloaded in 2014.⁶ Because sleep data collection relies on the smartphone being placed on the user’s mattress, movements of bed partners, pets, and bedding may interfere with results. In most cases, the apps display data in a format similar to that of fitness trackers. Some claim to determine the optimal sleep phase for the alarm to wake the user.

HOW DOES THE TECHNOLOGY WORK?

Older activity-tracking devices used single-channel electroencephalographic recordings or multiple physiologic channels such as galvanic skin response, skin temperature, and heat flux to measure activity to determine transitions between periods of sleep and wakefulness.^7,8

None of the currently available consumer sleep tracking devices discloses the exact mechanisms used to measure sleep and wakefulness, but most appear to rely on 3-axis accelerometers,⁹ ie, microelectromechanical devices that measure front-to-back, side-to-side, and up-and-down motion and convert the data into an activity count. Activity counts are acquired over 30- or 60-second intervals and are entered into algorithms that determine if the pattern indicates that the patient is awake or asleep. This is the same method that actigraphy uses to evaluate sleep, but most actigraphs used in medicine disclose their mechanisms and provide clinicians with the option of using various validated algorithms to classify the activity counts into sleep or awake periods.^9–11

ARE THE MEASURES VALID?

Only a few studies have examined the validity and accuracy of current fitness trackers and apps for measuring sleep.

The available studies are difficult to compare; most have been small and used different actigraphy devices for comparison. Some tested healthy volunteers, others included people with suspected or confirmed sleep disorders, and some had both types of participants. In many studies, the device was compared with polysomnography for only 1 night, making the “first-night effect” likely to be a confounding factor, as people tend to sleep worse during the first night of testing. Technical failures for the devices were noted in some studies.¹² In addition, some currently used apps may use different platforms than the devices used in these studies, limiting the extrapolation of results.

As with fitness trackers, few studies have been done to examine the validity of smartphone apps.⁵ Findings of 3 studies are summarized in Table 2.^17–19 In addition to tracking the duration and depth of sleep, some apps purport to detect snoring, sleep apnea, and periodic limb movements of sleep. Discussion of these apps is beyond the scope of this review.

ARE THE DEVICES CLINICALLY USEFUL?

Although a thorough history remains the cornerstone of a good evaluation of sleep problems, testing is sometimes essential, and in certain situations, objective data can complement the history and clarify the diagnosis.

Polysomnography remains the gold standard for telling when the patient is asleep vs awake, diagnosing sleep-disordered breathing, detecting periodic limb movements and parasomnias, and aiding in the diagnosis of narcolepsy.

Actigraphy, which uses technology similar to fitness trackers, can help distinguish sleep from wakefulness, reveal erratic sleep schedules, and help diagnose circadian rhythm sleep disorders. In patients with insomnia, actigraphy can help determine daily sleep patterns and response to treatment.²⁰ It can be especially useful for patients who cannot provide a clear history, eg, children and those with developmental disabilities or cognitive dysfunction.

Consumer sleep tracking devices, like actigraphy, are portable and unobtrusive, providing a way to measure sleep duration and demonstrate sleep patterns in a patient’s natural environment. Being more accessible, cheaper, and less time-consuming than clinical tests, the commercially available devices could be clinically useful in some situations, eg, for monitoring overall sleep patterns to look for circadian sleep-wake disorders, commonly seen in shift workers (shift work disorder) or adolescents (delayed sleep-wake phase disorder); or in patients with poor motivation to maintain a sleep diary. Because of their poor performance in clinical trials, they should not be relied upon to distinguish sleep from wakefulness, quantify the amount of sleep, determine sleep stages, and awaken patients exclusively from light sleep.

Discerning poor sleep hygiene from insomnia

Patients with insomnia tend to take longer to go to sleep (have longer sleep latencies), wake up more (have more disturbed sleep with increased awakenings), and have shorter sleep times with reduced sleep efficiencies.²¹ Sleep tracking devices tend to be less accurate for patients with short sleep duration and disturbed sleep, limiting their usefulness in this group. Furthermore, patients with insomnia tend to underestimate their sleep time and overestimate sleep latency; some devices also tend to overestimate the time to fall asleep, reinforcing this common error made by patients.^22,23

On the other hand, data from sleep tracking devices could help distinguish poor sleep hygiene from an insomnia disorder. For example, the data may indicate that a patient has poor sleep habits, such as taking long daytime naps or having significantly variable time in and out of bed from day to day. The total times asleep and awake in the middle of the night may also be substantially different on each night, which would also possibly indicate poor sleep hygiene.

Detecting circadian rhythms

A device may show that a patient has a clear circadian preference that is not in line with his or her daily routines, suggesting an underlying circadian rhythm sleep-wake disorder. This may be evident by bedtimes and wake times that are consistent but substantially out of sync with one’s social or occupational needs.

Measuring overall sleep duration

In people with normal sleep, fitness trackers perform reasonably well for measuring overall sleep duration. This information could be used to assess a patient with daytime sleepiness and fatigue to evaluate insufficient sleep as an etiologic factor.

Table 3 summarizes how to evaluate the data from sleep apps and fitness tracking devices for clinical use. While these features of consumer sleep tracking devices could conceivably help in the above clinical scenarios, further validation of devices in clinical populations is necessary before their use can be recommended without reservation.

ADVISING PATIENTS

Patients sometimes present to clinicians with concerns about the duration of sleep time and time spent in various sleep stages as delineated by their sleep tracking devices. Currently, these devices do not appear to be able to adequately distinguish various sleep stages, and in many users, they can substantially underestimate or overestimate sleep parameters such as time taken to fall asleep or duration of awakenings in the middle of the night. Patients can be reassured about this lack of evidence and should be advised to not place too much weight on such data alone.

Sleep “goals” set by many devices have not been scientifically validated. People without sleep problems should be discouraged from making substantial changes to their routines to accommodate sleep targets set by the devices. Patients should be counseled about the pitfalls of the data and can be reassured that little evidence suggests that time spent in various sleep stages correlates with adverse daytime consequences or with poor health outcomes.

Some of the apps used as alarm clocks claim to be able to tell what stage of sleep people are in and wait to awaken them until they are in a light stage, which is less jarring than being awakened from a deep stage, but the evidence for this is unclear. In the one study that tested this claim, the app did not awaken participants from light sleep more often than is likely to occur by chance.¹⁷ The utility of these apps as personalized alarm clocks is still extremely limited, and patients should be counseled to obtain an adequate amount of sleep rather than rely on devices to awaken them during specific sleep stages.

The rates for discontinuing the use of these devices are high, which could limit their utility. Some surveys have shown that close to 50% of users stop using fitness trackers; 33% stop using them within 6 months of obtaining the device.²⁴ Also, there is little evidence that close monitoring of sleep results in behavior changes or improved sleep duration. Conversely, the potential harms of excessive monitoring of one’s sleep are currently unknown.

PORTLAND, ORE. – Among white men, the presence of at least one cutaneous nevus measuring 3 mm or more significantly predicted death from melanoma, in an adjusted analysis of a large prospective cohort study.

Mole count also predicted melanoma death among white women, but the association reached statistical significance only when women had at least three cutaneous nevi measuring 3 mm or more, Eunyoung Cho, ScD, said at the annual meeting of the Society for Investigative Dermatology. The reasons why these associations varied by sex is unclear, although previous studies have documented higher rates of melanoma death among men than among women, and even male physicians tend to seek health care less frequently than their female counterparts, Dr. Cho said in her poster presentation.

PORTLAND, ORE. – Among white men, the presence of at least one cutaneous nevus measuring 3 mm or more significantly predicted death from melanoma, in an adjusted analysis of a large prospective cohort study.

Mole count also predicted melanoma death among white women, but the association reached statistical significance only when women had at least three cutaneous nevi measuring 3 mm or more, Eunyoung Cho, ScD, said at the annual meeting of the Society for Investigative Dermatology. The reasons why these associations varied by sex is unclear, although previous studies have documented higher rates of melanoma death among men than among women, and even male physicians tend to seek health care less frequently than their female counterparts, Dr. Cho said in her poster presentation.

PORTLAND, ORE. – Among white men, the presence of at least one cutaneous nevus measuring 3 mm or more significantly predicted death from melanoma, in an adjusted analysis of a large prospective cohort study.

Mole count also predicted melanoma death among white women, but the association reached statistical significance only when women had at least three cutaneous nevi measuring 3 mm or more, Eunyoung Cho, ScD, said at the annual meeting of the Society for Investigative Dermatology. The reasons why these associations varied by sex is unclear, although previous studies have documented higher rates of melanoma death among men than among women, and even male physicians tend to seek health care less frequently than their female counterparts, Dr. Cho said in her poster presentation.

Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.

Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.¹ Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Resources

1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)

2. Pediatrics. 2014 Sep;134(3):e921-32.

3. Sleep. 2004 Nov 1;27(7):1351-8.

Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.

Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.¹ Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Resources

1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)

2. Pediatrics. 2014 Sep;134(3):e921-32.

3. Sleep. 2004 Nov 1;27(7):1351-8.

Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.

Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.¹ Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Resources

1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)

2. Pediatrics. 2014 Sep;134(3):e921-32.

3. Sleep. 2004 Nov 1;27(7):1351-8.

Women are less likely to be diagnosed with and treated for sleep-disordered breathing, despite having symptoms similar to those of men, a Swedish study showed.

In a survey of 10,854 subjects, 14% of women reported being diagnosed with obstructive sleep apnea (OSA), compared with 25% of men (P less than .001), and 9% of women reported having any OSA treatment, compared with 16% of men (Sleep Med. 2017. doi: 10.1016/j.sleep.2017.02.032).

Underdiagnosis of sleep-disordered breathing (SDB) in women may have dire consequences, as symptoms, specifically snoring and excessive daytime sleepiness (EDS), correlate with increased risk for hypertension and diabetes, regardless of gender, according to Eva Lindberg, PhD, professor in the department of medical sciences, respiratory, allergy, and sleep research at Uppsala (Sweden) University, and her colleagues.

The mean age of the patients at baseline was 41 years. Mean body mass index was 25.4 kg/m2 for men and 24 kg/m2 for women.

On initial testing, approximately three times the percentage of men reported having issues with snoring and no EDS, compared with women (19% vs. 6% respectively), while more women reported the opposite, EDS but no snoring (19% vs. 11%). A slightly larger percentage of men reported having both symptoms (7.3% vs. 4.5%).

Investigators hypothesized the disparity between women and men reporting problems with snoring may be caused by gender expectations.

“It is more probable that SDB is still assumed to be a condition associated predominantly with men, and women feel ashamed of reporting these symptoms and seeking medical advice,” said Dr. Lindberg and her coinvestigators. These gender expectations may “contribute to females being less inclined to seek medical advice due to SDB symptoms.”

In a follow-up survey conducted 11 years after the initial one, doctors found 1,716 and 319 patients had received a new diagnosis for hypertension and diabetes, respectively.

While incidence was greater in men than in women for both (hypertension: 18.6% vs. 15.8% [P less than .001] and 3.6 vs. 2.4% [P less than .001], respectively), the investigators found “after adjusting for BMI and snoring at baseline, none of these gender differences remained significant.”

Physicians’ perception of SDB is partially responsible for the number of women who go undiagnosed, according to the researchers. Because SDB is considered to occur predominantly in males, doctors may overlook symptoms in female patients that would otherwise be a cause for further testing, they noted.

“[Even] among health professionals, SDB is still usually attributed to a male population, and female patients are therefore less frequently asked about the cardinal symptoms of snoring and sleepiness and do not therefore undergo sleep recordings. ... Also, among patients with obesity hypoventilation syndrome, females are generally diagnosed when the disease is more advanced and significantly more frequently develop acute disease before achieving treatment,” the investigators wrote.

“[Even] among health professionals, SDB is still usually attributed to a male population and female patients are therefore less frequently asked about the cardinal symptoms of snoring and sleepiness and do not therefore undergo sleep recordings ... Also, among patients with obesity hypoventilation syndrome, females are generally diagnosed when the disease is more advanced and significantly more frequently develop acute disease before achieving treatment,” the investigators claimed.

Dr. Lindberg and her team suggested engaging female patients more frequently about SDB symptoms, as well as referring patients with positive symptoms to participate in a sleep study.

The current study was limited by the nature of the data, which were self-reported. Patients were not surveyed via the Epworth Sleepiness Scale.

The study was funded by grants from the Norwegian Research Council, the Icelandic Research Council, Aarhus University, the Swedish Heart-Lung Foundation, and the Estonian Science Foundation.

The investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

Women are less likely to be diagnosed with and treated for sleep-disordered breathing, despite having symptoms similar to those of men, a Swedish study showed.

In a survey of 10,854 subjects, 14% of women reported being diagnosed with obstructive sleep apnea (OSA), compared with 25% of men (P less than .001), and 9% of women reported having any OSA treatment, compared with 16% of men (Sleep Med. 2017. doi: 10.1016/j.sleep.2017.02.032).

Underdiagnosis of sleep-disordered breathing (SDB) in women may have dire consequences, as symptoms, specifically snoring and excessive daytime sleepiness (EDS), correlate with increased risk for hypertension and diabetes, regardless of gender, according to Eva Lindberg, PhD, professor in the department of medical sciences, respiratory, allergy, and sleep research at Uppsala (Sweden) University, and her colleagues.

The mean age of the patients at baseline was 41 years. Mean body mass index was 25.4 kg/m2 for men and 24 kg/m2 for women.

On initial testing, approximately three times the percentage of men reported having issues with snoring and no EDS, compared with women (19% vs. 6% respectively), while more women reported the opposite, EDS but no snoring (19% vs. 11%). A slightly larger percentage of men reported having both symptoms (7.3% vs. 4.5%).

Investigators hypothesized the disparity between women and men reporting problems with snoring may be caused by gender expectations.

“It is more probable that SDB is still assumed to be a condition associated predominantly with men, and women feel ashamed of reporting these symptoms and seeking medical advice,” said Dr. Lindberg and her coinvestigators. These gender expectations may “contribute to females being less inclined to seek medical advice due to SDB symptoms.”

In a follow-up survey conducted 11 years after the initial one, doctors found 1,716 and 319 patients had received a new diagnosis for hypertension and diabetes, respectively.

While incidence was greater in men than in women for both (hypertension: 18.6% vs. 15.8% [P less than .001] and 3.6 vs. 2.4% [P less than .001], respectively), the investigators found “after adjusting for BMI and snoring at baseline, none of these gender differences remained significant.”

Physicians’ perception of SDB is partially responsible for the number of women who go undiagnosed, according to the researchers. Because SDB is considered to occur predominantly in males, doctors may overlook symptoms in female patients that would otherwise be a cause for further testing, they noted.

“[Even] among health professionals, SDB is still usually attributed to a male population, and female patients are therefore less frequently asked about the cardinal symptoms of snoring and sleepiness and do not therefore undergo sleep recordings. ... Also, among patients with obesity hypoventilation syndrome, females are generally diagnosed when the disease is more advanced and significantly more frequently develop acute disease before achieving treatment,” the investigators wrote.

“[Even] among health professionals, SDB is still usually attributed to a male population and female patients are therefore less frequently asked about the cardinal symptoms of snoring and sleepiness and do not therefore undergo sleep recordings ... Also, among patients with obesity hypoventilation syndrome, females are generally diagnosed when the disease is more advanced and significantly more frequently develop acute disease before achieving treatment,” the investigators claimed.

Dr. Lindberg and her team suggested engaging female patients more frequently about SDB symptoms, as well as referring patients with positive symptoms to participate in a sleep study.

The current study was limited by the nature of the data, which were self-reported. Patients were not surveyed via the Epworth Sleepiness Scale.

The study was funded by grants from the Norwegian Research Council, the Icelandic Research Council, Aarhus University, the Swedish Heart-Lung Foundation, and the Estonian Science Foundation.

The investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

Women are less likely to be diagnosed with and treated for sleep-disordered breathing, despite having symptoms similar to those of men, a Swedish study showed.

In a survey of 10,854 subjects, 14% of women reported being diagnosed with obstructive sleep apnea (OSA), compared with 25% of men (P less than .001), and 9% of women reported having any OSA treatment, compared with 16% of men (Sleep Med. 2017. doi: 10.1016/j.sleep.2017.02.032).

Underdiagnosis of sleep-disordered breathing (SDB) in women may have dire consequences, as symptoms, specifically snoring and excessive daytime sleepiness (EDS), correlate with increased risk for hypertension and diabetes, regardless of gender, according to Eva Lindberg, PhD, professor in the department of medical sciences, respiratory, allergy, and sleep research at Uppsala (Sweden) University, and her colleagues.

The mean age of the patients at baseline was 41 years. Mean body mass index was 25.4 kg/m2 for men and 24 kg/m2 for women.

On initial testing, approximately three times the percentage of men reported having issues with snoring and no EDS, compared with women (19% vs. 6% respectively), while more women reported the opposite, EDS but no snoring (19% vs. 11%). A slightly larger percentage of men reported having both symptoms (7.3% vs. 4.5%).

Investigators hypothesized the disparity between women and men reporting problems with snoring may be caused by gender expectations.

“It is more probable that SDB is still assumed to be a condition associated predominantly with men, and women feel ashamed of reporting these symptoms and seeking medical advice,” said Dr. Lindberg and her coinvestigators. These gender expectations may “contribute to females being less inclined to seek medical advice due to SDB symptoms.”

In a follow-up survey conducted 11 years after the initial one, doctors found 1,716 and 319 patients had received a new diagnosis for hypertension and diabetes, respectively.

While incidence was greater in men than in women for both (hypertension: 18.6% vs. 15.8% [P less than .001] and 3.6 vs. 2.4% [P less than .001], respectively), the investigators found “after adjusting for BMI and snoring at baseline, none of these gender differences remained significant.”

Physicians’ perception of SDB is partially responsible for the number of women who go undiagnosed, according to the researchers. Because SDB is considered to occur predominantly in males, doctors may overlook symptoms in female patients that would otherwise be a cause for further testing, they noted.

“[Even] among health professionals, SDB is still usually attributed to a male population, and female patients are therefore less frequently asked about the cardinal symptoms of snoring and sleepiness and do not therefore undergo sleep recordings. ... Also, among patients with obesity hypoventilation syndrome, females are generally diagnosed when the disease is more advanced and significantly more frequently develop acute disease before achieving treatment,” the investigators wrote.

“[Even] among health professionals, SDB is still usually attributed to a male population and female patients are therefore less frequently asked about the cardinal symptoms of snoring and sleepiness and do not therefore undergo sleep recordings ... Also, among patients with obesity hypoventilation syndrome, females are generally diagnosed when the disease is more advanced and significantly more frequently develop acute disease before achieving treatment,” the investigators claimed.

Dr. Lindberg and her team suggested engaging female patients more frequently about SDB symptoms, as well as referring patients with positive symptoms to participate in a sleep study.

The current study was limited by the nature of the data, which were self-reported. Patients were not surveyed via the Epworth Sleepiness Scale.

The study was funded by grants from the Norwegian Research Council, the Icelandic Research Council, Aarhus University, the Swedish Heart-Lung Foundation, and the Estonian Science Foundation.

The investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

WASHINGTON – Oxygen desaturation index (ODI) scores showed significant variation across two software systems, a study showed.

The researchers assessed the ODI scores of 106 patients using the ResMed ApneaLink Plus system (AL) and the Compumedics Grael Profusion PSG3 system (Comp). “AL ODI values tended to be higher than Comp ODI values, but with significant variability,” they said.

AL  showed a bias of an additional 4.4 events per hour (95% limits of agreement, –5.8 to 14.6 events per hour) for ODI scores at 4% desaturation and a bias of an additional 7.1 events per hour (95% limits of agreement, –6.4 to 20.6 events per hour) at 3% desaturation (J Clin Sleep Med. 2017;13[4]:599-605).

This may be problematic for physicians evaluating patients during sleep studies who rely on ODI scores at 3% and 4% desaturations to create accurate apnea severity assessments, the investigators said.

“[The] wide limits of agreement in our study highlight that clinicians cannot be confident that an ODI4% recorded in the AL is the same as that recorded in the Comp,” wrote Yvonne Ng, MBBS, of the department of lung and sleep medicine at Monash Health, Victoria, Australia, and her colleagues. “The differences are large enough to significantly affect diagnostic thresholds for OSA [obstructive sleep apnea] and, in particular, moderate-severe OSA.”

The researchers gathered data from patients undergoing sleep analysis at the Monash Medical Centre, who were, on average, 47 years of age, had a body mass index score of 32 kg/m2, and had an apnea hypopnea index (AHI) of 23.2.

ODI3% scores analyzed through Comp diagnosed 66 patients with OSA (ODI3% greater than or equal to 5 events per hour), while desaturation events analyzed through the AL system diagnosed 90 patients, a 36% increase over Comp (P = .0002).

When researchers tested for moderate to severe OSA (ODI3% greater than or equal to 15 events per hour), 32 patients were diagnosed using the Comp system, compared with 59 patients using the AL system.

Disparities in these measurements create uncertainty among clinicians, who rely on ODI measurements for scores that are accurate and can be easily replicated using an algorithm, the researchers said.

“The current work demonstrates that significantly more patients would receive a diagnosis of OSA, or more particularly, moderate-severe OSA, with the AL ODI, compared to the Comp ODI,” Dr. Ng and her colleagues wrote.

When sensitivity scores for Comp and AL were compared, AL ODI3% scores were significantly more sensitive than Comp, with sensitivity scores of 96% vs. 58%.

Using different fingers for measuring desaturation during the test or differences in algorithms used to assess ODI scores were possible sources of the disparities, the researchers noted.

Differences in internal processing between the two systems were the most likely causes of the discrepancies between the data collected using each system, they added.

Because there is no universal standard for ODI measurements, the researchers were unable to determine which system was more accurate.

Several of the researchers reported receiving financial support, research equipment, or consultancy fees from various entities.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

WASHINGTON – Oxygen desaturation index (ODI) scores showed significant variation across two software systems, a study showed.

The researchers assessed the ODI scores of 106 patients using the ResMed ApneaLink Plus system (AL) and the Compumedics Grael Profusion PSG3 system (Comp). “AL ODI values tended to be higher than Comp ODI values, but with significant variability,” they said.

AL  showed a bias of an additional 4.4 events per hour (95% limits of agreement, –5.8 to 14.6 events per hour) for ODI scores at 4% desaturation and a bias of an additional 7.1 events per hour (95% limits of agreement, –6.4 to 20.6 events per hour) at 3% desaturation (J Clin Sleep Med. 2017;13[4]:599-605).

This may be problematic for physicians evaluating patients during sleep studies who rely on ODI scores at 3% and 4% desaturations to create accurate apnea severity assessments, the investigators said.

“[The] wide limits of agreement in our study highlight that clinicians cannot be confident that an ODI4% recorded in the AL is the same as that recorded in the Comp,” wrote Yvonne Ng, MBBS, of the department of lung and sleep medicine at Monash Health, Victoria, Australia, and her colleagues. “The differences are large enough to significantly affect diagnostic thresholds for OSA [obstructive sleep apnea] and, in particular, moderate-severe OSA.”

The researchers gathered data from patients undergoing sleep analysis at the Monash Medical Centre, who were, on average, 47 years of age, had a body mass index score of 32 kg/m2, and had an apnea hypopnea index (AHI) of 23.2.

ODI3% scores analyzed through Comp diagnosed 66 patients with OSA (ODI3% greater than or equal to 5 events per hour), while desaturation events analyzed through the AL system diagnosed 90 patients, a 36% increase over Comp (P = .0002).

When researchers tested for moderate to severe OSA (ODI3% greater than or equal to 15 events per hour), 32 patients were diagnosed using the Comp system, compared with 59 patients using the AL system.

Disparities in these measurements create uncertainty among clinicians, who rely on ODI measurements for scores that are accurate and can be easily replicated using an algorithm, the researchers said.

“The current work demonstrates that significantly more patients would receive a diagnosis of OSA, or more particularly, moderate-severe OSA, with the AL ODI, compared to the Comp ODI,” Dr. Ng and her colleagues wrote.

When sensitivity scores for Comp and AL were compared, AL ODI3% scores were significantly more sensitive than Comp, with sensitivity scores of 96% vs. 58%.

Using different fingers for measuring desaturation during the test or differences in algorithms used to assess ODI scores were possible sources of the disparities, the researchers noted.

Differences in internal processing between the two systems were the most likely causes of the discrepancies between the data collected using each system, they added.

Because there is no universal standard for ODI measurements, the researchers were unable to determine which system was more accurate.

Several of the researchers reported receiving financial support, research equipment, or consultancy fees from various entities.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

WASHINGTON – Oxygen desaturation index (ODI) scores showed significant variation across two software systems, a study showed.

The researchers assessed the ODI scores of 106 patients using the ResMed ApneaLink Plus system (AL) and the Compumedics Grael Profusion PSG3 system (Comp). “AL ODI values tended to be higher than Comp ODI values, but with significant variability,” they said.

AL  showed a bias of an additional 4.4 events per hour (95% limits of agreement, –5.8 to 14.6 events per hour) for ODI scores at 4% desaturation and a bias of an additional 7.1 events per hour (95% limits of agreement, –6.4 to 20.6 events per hour) at 3% desaturation (J Clin Sleep Med. 2017;13[4]:599-605).

This may be problematic for physicians evaluating patients during sleep studies who rely on ODI scores at 3% and 4% desaturations to create accurate apnea severity assessments, the investigators said.

“[The] wide limits of agreement in our study highlight that clinicians cannot be confident that an ODI4% recorded in the AL is the same as that recorded in the Comp,” wrote Yvonne Ng, MBBS, of the department of lung and sleep medicine at Monash Health, Victoria, Australia, and her colleagues. “The differences are large enough to significantly affect diagnostic thresholds for OSA [obstructive sleep apnea] and, in particular, moderate-severe OSA.”

The researchers gathered data from patients undergoing sleep analysis at the Monash Medical Centre, who were, on average, 47 years of age, had a body mass index score of 32 kg/m2, and had an apnea hypopnea index (AHI) of 23.2.

ODI3% scores analyzed through Comp diagnosed 66 patients with OSA (ODI3% greater than or equal to 5 events per hour), while desaturation events analyzed through the AL system diagnosed 90 patients, a 36% increase over Comp (P = .0002).

When researchers tested for moderate to severe OSA (ODI3% greater than or equal to 15 events per hour), 32 patients were diagnosed using the Comp system, compared with 59 patients using the AL system.

Disparities in these measurements create uncertainty among clinicians, who rely on ODI measurements for scores that are accurate and can be easily replicated using an algorithm, the researchers said.

“The current work demonstrates that significantly more patients would receive a diagnosis of OSA, or more particularly, moderate-severe OSA, with the AL ODI, compared to the Comp ODI,” Dr. Ng and her colleagues wrote.

When sensitivity scores for Comp and AL were compared, AL ODI3% scores were significantly more sensitive than Comp, with sensitivity scores of 96% vs. 58%.

Using different fingers for measuring desaturation during the test or differences in algorithms used to assess ODI scores were possible sources of the disparities, the researchers noted.

Differences in internal processing between the two systems were the most likely causes of the discrepancies between the data collected using each system, they added.

Because there is no universal standard for ODI measurements, the researchers were unable to determine which system was more accurate.

Several of the researchers reported receiving financial support, research equipment, or consultancy fees from various entities.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Most adults experience problems with sleep from time to time, and 6%-10% meet diagnostic criteria for chronic insomnia. Many of these patients present to their primary care clinicians looking for help. This clinical practice guideline from the American College of Physicians provides recommendations based on a review of studies published during the previous decade, which were assessed in terms of the strength of the recommendation and the quality of evidence. The guideline resulted in two recommendations:

1: All adult patients should receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia. (strong recommendation)

2: Clinicians should use a shared decision-making approach discussing the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (weak recommendation)

Cognitive behavioral therapy for insomnia (CBT-I)

Cognitive behavioral therapy for insomnia encompasses a variety of measures that aim to change patients’ habits and beliefs associated with sleep. These measures include general “sleep hygiene” interventions, as well as stimulus control, sleep restriction, relaxation training, and cognitive reframing. With sleep hygiene, patients are educated about environmental factors that affect sleep, such as avoiding caffeine late in the day, limiting alcohol intake, having a regular sleep schedule, avoiding napping, the importance of exercise, and the importance of a quiet dark room in which to sleep. Examples of stimulus control include going to bed only when sleepy, and avoiding reading and watching TV in the bedroom. Sleep restriction limits the time in bed with strict sleep and wake-up times, gradually increasing time in bed as sleep efficiency improves.

Clinicians may find it surprising that this guideline makes such a strong, clear case for the primacy of behavioral measures in the treatment of chronic insomnia. The authors make a number of points in support of this position.

First, the effects of behavioral interventions appear to be robust – at least comparable to the short-term effects of medications – and often significantly better. For example, various studies of CBT-I show a decrease in sleep onset latency (how long it takes to fall asleep after going to bed) of between 12 and 31 minutes and an increase in total sleep time of 40 minutes. This compares favorably to the short-term effects of commonly used sleep medications.

Second, the effects of behavioral interventions are long-lasting compared with medications, which are usually approved for only short-term use, lose effectiveness over time, and have no benefit at all once they’re no longer being taken. Finally, there appear to be no harms associated with CBT-I, compared with significant adverse effects of medications.

One challenge is that access to effective behavioral interventions for insomnia can be an issue. On the other hand, a number of behavioral delivery methods were examined, and found to be effective, including in-person individual or group therapy, telephone- or Web-based modules or apps, and self-help books. An editorial accompanying the guidelines calls for efforts to increase the availability of behavioral modalities for insomnia.

Pharmacologic therapy

The recommendation to use pharmacologic therapy for insomnia is much more qualified than that for CBT-I, with language about shared decision-making, discussion of risks and benefits, emphasis on short-term use, and a provision that it be used only after an unsatisfactory trial of CBT-I alone. In addition, this recommendation is classified as “weak,” and the associated evidence “low-quality.” Medications reviewed included eszopiclone, zaleplon, zolpidem, orexin receptor antagonist, melatonin, ramelteon, and benzodiazepines.

There are several reasons why pharmacologic therapy is deemphasized. First, as noted above, the effects of commonly used medications are modest. As an example, typical patients with chronic insomnia will have sleep-onset latency of 60-70 minutes. Medications reviewed for this guideline decreased this time by approximately 10-20 minutes in short-term studies, so patients still took 40-60 minutes to fall asleep. Similar modest short-term effects were seen in terms of increasing total sleep time.

A second issue with pharmacologic therapy is that while many patients with chronic insomnia seek to use medications long term, the available studies have tended to look only at short-term use, and those studies with longer duration show a diminution of medication effect over time.

Finally, there are significant adverse effects associated with sedative-hypnotic medications, including somnolence, anxiety, confusion, and disturbance in attention. This is problematic, considering that these are precisely the symptoms that patients may be hoping to avoid when they take medications to help them sleep. Even patients who may not feel impaired often show demonstrable deficits in attention and performance following use of sleep medications; this issue is reflected in the boxed warnings that accompany several commonly prescribed agents.

It is noted in the evidence reviews that there are differences among the available medications. The nonbenzodiazepine hypnotics eszopiclone and zolpidem as well as the orexin receptor antagonist suvorexant improved short-term sleep quality, though the effect was small and there was significant evidence of harm as described above. Benzodiazepine hypnotics, melatonin agonists, and antidepressants studied had little or low-quality evidence to support efficacy on improving sleep. For melatonin and ramelteon, the evidence review notes that adverse effects did not differ between the medication and the placebo groups, though two open-label longer-term studies showed evidence of adverse effects with ramelteon. It is also important to note that patients studied in medication trials were mostly healthy middle-aged individuals; it is possible that the side effects of sleep medications may be greater in those who are older or more infirm.
 

Bottom line

This guideline from the American College of Physicians strongly endorses the use of tailored cognitive behavioral therapy modalities for the initial treatment of patients with chronic insomnia. Medications are given a weak recommendation for a limited back-up role.

Dr. Clark is associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

References

Qaseem A, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165:125-33.

Brasure M. Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med. 2016;165:113-24.

Wilt TJ, et al. Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med. 2016;165:103-12.

Most adults experience problems with sleep from time to time, and 6%-10% meet diagnostic criteria for chronic insomnia. Many of these patients present to their primary care clinicians looking for help. This clinical practice guideline from the American College of Physicians provides recommendations based on a review of studies published during the previous decade, which were assessed in terms of the strength of the recommendation and the quality of evidence. The guideline resulted in two recommendations:

1: All adult patients should receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia. (strong recommendation)

2: Clinicians should use a shared decision-making approach discussing the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (weak recommendation)

Cognitive behavioral therapy for insomnia (CBT-I)

Cognitive behavioral therapy for insomnia encompasses a variety of measures that aim to change patients’ habits and beliefs associated with sleep. These measures include general “sleep hygiene” interventions, as well as stimulus control, sleep restriction, relaxation training, and cognitive reframing. With sleep hygiene, patients are educated about environmental factors that affect sleep, such as avoiding caffeine late in the day, limiting alcohol intake, having a regular sleep schedule, avoiding napping, the importance of exercise, and the importance of a quiet dark room in which to sleep. Examples of stimulus control include going to bed only when sleepy, and avoiding reading and watching TV in the bedroom. Sleep restriction limits the time in bed with strict sleep and wake-up times, gradually increasing time in bed as sleep efficiency improves.

Clinicians may find it surprising that this guideline makes such a strong, clear case for the primacy of behavioral measures in the treatment of chronic insomnia. The authors make a number of points in support of this position.

First, the effects of behavioral interventions appear to be robust – at least comparable to the short-term effects of medications – and often significantly better. For example, various studies of CBT-I show a decrease in sleep onset latency (how long it takes to fall asleep after going to bed) of between 12 and 31 minutes and an increase in total sleep time of 40 minutes. This compares favorably to the short-term effects of commonly used sleep medications.

Second, the effects of behavioral interventions are long-lasting compared with medications, which are usually approved for only short-term use, lose effectiveness over time, and have no benefit at all once they’re no longer being taken. Finally, there appear to be no harms associated with CBT-I, compared with significant adverse effects of medications.

One challenge is that access to effective behavioral interventions for insomnia can be an issue. On the other hand, a number of behavioral delivery methods were examined, and found to be effective, including in-person individual or group therapy, telephone- or Web-based modules or apps, and self-help books. An editorial accompanying the guidelines calls for efforts to increase the availability of behavioral modalities for insomnia.

Pharmacologic therapy

The recommendation to use pharmacologic therapy for insomnia is much more qualified than that for CBT-I, with language about shared decision-making, discussion of risks and benefits, emphasis on short-term use, and a provision that it be used only after an unsatisfactory trial of CBT-I alone. In addition, this recommendation is classified as “weak,” and the associated evidence “low-quality.” Medications reviewed included eszopiclone, zaleplon, zolpidem, orexin receptor antagonist, melatonin, ramelteon, and benzodiazepines.

There are several reasons why pharmacologic therapy is deemphasized. First, as noted above, the effects of commonly used medications are modest. As an example, typical patients with chronic insomnia will have sleep-onset latency of 60-70 minutes. Medications reviewed for this guideline decreased this time by approximately 10-20 minutes in short-term studies, so patients still took 40-60 minutes to fall asleep. Similar modest short-term effects were seen in terms of increasing total sleep time.

A second issue with pharmacologic therapy is that while many patients with chronic insomnia seek to use medications long term, the available studies have tended to look only at short-term use, and those studies with longer duration show a diminution of medication effect over time.

Finally, there are significant adverse effects associated with sedative-hypnotic medications, including somnolence, anxiety, confusion, and disturbance in attention. This is problematic, considering that these are precisely the symptoms that patients may be hoping to avoid when they take medications to help them sleep. Even patients who may not feel impaired often show demonstrable deficits in attention and performance following use of sleep medications; this issue is reflected in the boxed warnings that accompany several commonly prescribed agents.

It is noted in the evidence reviews that there are differences among the available medications. The nonbenzodiazepine hypnotics eszopiclone and zolpidem as well as the orexin receptor antagonist suvorexant improved short-term sleep quality, though the effect was small and there was significant evidence of harm as described above. Benzodiazepine hypnotics, melatonin agonists, and antidepressants studied had little or low-quality evidence to support efficacy on improving sleep. For melatonin and ramelteon, the evidence review notes that adverse effects did not differ between the medication and the placebo groups, though two open-label longer-term studies showed evidence of adverse effects with ramelteon. It is also important to note that patients studied in medication trials were mostly healthy middle-aged individuals; it is possible that the side effects of sleep medications may be greater in those who are older or more infirm.
 

Bottom line

This guideline from the American College of Physicians strongly endorses the use of tailored cognitive behavioral therapy modalities for the initial treatment of patients with chronic insomnia. Medications are given a weak recommendation for a limited back-up role.

Dr. Clark is associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

References

Qaseem A, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165:125-33.

Brasure M. Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med. 2016;165:113-24.

Wilt TJ, et al. Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med. 2016;165:103-12.

Most adults experience problems with sleep from time to time, and 6%-10% meet diagnostic criteria for chronic insomnia. Many of these patients present to their primary care clinicians looking for help. This clinical practice guideline from the American College of Physicians provides recommendations based on a review of studies published during the previous decade, which were assessed in terms of the strength of the recommendation and the quality of evidence. The guideline resulted in two recommendations:

1: All adult patients should receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia. (strong recommendation)

2: Clinicians should use a shared decision-making approach discussing the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (weak recommendation)

Cognitive behavioral therapy for insomnia (CBT-I)

Cognitive behavioral therapy for insomnia encompasses a variety of measures that aim to change patients’ habits and beliefs associated with sleep. These measures include general “sleep hygiene” interventions, as well as stimulus control, sleep restriction, relaxation training, and cognitive reframing. With sleep hygiene, patients are educated about environmental factors that affect sleep, such as avoiding caffeine late in the day, limiting alcohol intake, having a regular sleep schedule, avoiding napping, the importance of exercise, and the importance of a quiet dark room in which to sleep. Examples of stimulus control include going to bed only when sleepy, and avoiding reading and watching TV in the bedroom. Sleep restriction limits the time in bed with strict sleep and wake-up times, gradually increasing time in bed as sleep efficiency improves.

Clinicians may find it surprising that this guideline makes such a strong, clear case for the primacy of behavioral measures in the treatment of chronic insomnia. The authors make a number of points in support of this position.

First, the effects of behavioral interventions appear to be robust – at least comparable to the short-term effects of medications – and often significantly better. For example, various studies of CBT-I show a decrease in sleep onset latency (how long it takes to fall asleep after going to bed) of between 12 and 31 minutes and an increase in total sleep time of 40 minutes. This compares favorably to the short-term effects of commonly used sleep medications.

Second, the effects of behavioral interventions are long-lasting compared with medications, which are usually approved for only short-term use, lose effectiveness over time, and have no benefit at all once they’re no longer being taken. Finally, there appear to be no harms associated with CBT-I, compared with significant adverse effects of medications.

One challenge is that access to effective behavioral interventions for insomnia can be an issue. On the other hand, a number of behavioral delivery methods were examined, and found to be effective, including in-person individual or group therapy, telephone- or Web-based modules or apps, and self-help books. An editorial accompanying the guidelines calls for efforts to increase the availability of behavioral modalities for insomnia.

Pharmacologic therapy

The recommendation to use pharmacologic therapy for insomnia is much more qualified than that for CBT-I, with language about shared decision-making, discussion of risks and benefits, emphasis on short-term use, and a provision that it be used only after an unsatisfactory trial of CBT-I alone. In addition, this recommendation is classified as “weak,” and the associated evidence “low-quality.” Medications reviewed included eszopiclone, zaleplon, zolpidem, orexin receptor antagonist, melatonin, ramelteon, and benzodiazepines.

There are several reasons why pharmacologic therapy is deemphasized. First, as noted above, the effects of commonly used medications are modest. As an example, typical patients with chronic insomnia will have sleep-onset latency of 60-70 minutes. Medications reviewed for this guideline decreased this time by approximately 10-20 minutes in short-term studies, so patients still took 40-60 minutes to fall asleep. Similar modest short-term effects were seen in terms of increasing total sleep time.

A second issue with pharmacologic therapy is that while many patients with chronic insomnia seek to use medications long term, the available studies have tended to look only at short-term use, and those studies with longer duration show a diminution of medication effect over time.

Finally, there are significant adverse effects associated with sedative-hypnotic medications, including somnolence, anxiety, confusion, and disturbance in attention. This is problematic, considering that these are precisely the symptoms that patients may be hoping to avoid when they take medications to help them sleep. Even patients who may not feel impaired often show demonstrable deficits in attention and performance following use of sleep medications; this issue is reflected in the boxed warnings that accompany several commonly prescribed agents.

It is noted in the evidence reviews that there are differences among the available medications. The nonbenzodiazepine hypnotics eszopiclone and zolpidem as well as the orexin receptor antagonist suvorexant improved short-term sleep quality, though the effect was small and there was significant evidence of harm as described above. Benzodiazepine hypnotics, melatonin agonists, and antidepressants studied had little or low-quality evidence to support efficacy on improving sleep. For melatonin and ramelteon, the evidence review notes that adverse effects did not differ between the medication and the placebo groups, though two open-label longer-term studies showed evidence of adverse effects with ramelteon. It is also important to note that patients studied in medication trials were mostly healthy middle-aged individuals; it is possible that the side effects of sleep medications may be greater in those who are older or more infirm.
 

Bottom line

This guideline from the American College of Physicians strongly endorses the use of tailored cognitive behavioral therapy modalities for the initial treatment of patients with chronic insomnia. Medications are given a weak recommendation for a limited back-up role.

Dr. Clark is associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

References

Qaseem A, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165:125-33.

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