Cognitive-Behavioral and Pharmacological Treatments for Insomnia: A Combined Approach

Insomnia is the most prevalent sleep disorder (10-40%). It is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and that results in some form of daytime impairment. Among the typical symptoms, there are fatigue, decreased mood or irritability, general malaise, and cognitive impairment. According to the International Classification of Sleep Disorders 3rd edition, ICSD-3, it has been defined as chronic (lasting more than three months) or short-term insomnia (less than three months).In clinical practice, the usual therapeutic approach is pharmacological (benzodiazepines, z drugs, slow wave sleep enhancers), even if the American Academy of Sleep Medicine (AASM), the American College of Physicians (ACP), and the European Sleep Research Society (ESRS) guidelines suggest that the first clinical choice should be non-pharmacological (cognitive behavioral therapy). A combined (non-pharmacological and pharmacological)approach could be considered in poor responders to manage drug dependence and to increase compliance to treatment and patients' quality of life

Assessing REM sleep behaviour disorder: from machine learning classification to the definition of a continuous dissociation index

Objectives: Rapid Eye Movement Sleep Behaviour Disorder (RBD) is regarded as a pro-drome of neurodegeneration, with a high conversion rate to α–synucleinopathies such as Parkinson’s Disease (PD). The clinical diagnosis of RBD co–exists with evidence of REM Sleep Without Atonia (RSWA), a parasomnia that features loss of physiological muscular atonia during REM sleep. The objectives of this study are to implement an automatic detection of RSWA from polysomnographic traces, and to propose a continuous index (the Dissociation Index) to assess the level of dissociation between REM sleep stage and atonia. This is performed using Euclidean distance in proper vector spaces. Each subject is assigned a dissociation degree based on their distance from a reference, encompassing healthy subjects and clinically diagnosed RBD patients at the two extremes. Methods: Machine Learning models were employed to perform automatic identification of patients with RSWA through clinical polysomnographic scores, together with variables derived from electromyography. Proper distance metrics are proposed and tested to achieve a dissociation measure. Results: The method proved efficient in classifying RSWA vs. not-RSWA subjects, achieving an overall accuracy, sensitivity and precision of 87%, 93% and 87.5%, respectively. On its part, the Dissociation Index proved to be promising in measuring the impairment level of patients. Conclusions: The proposed method moves a step forward in the direction of automatically identifying REM sleep disorders and evaluating the impairment degree. We believe that this index may be correlated with the patients’ neurodegeneration process; this assumption will undergo a robust clinical validation process involving healthy, RSWA, RBD and PD subjects

Obstructive sleep apnea syndrome and cognitive impairment: effects of CPAP

Obstructive Sleep Apnea Syndrome (OSAS) is a sleep disorder characterised by repetitive episodes of upper airway obstruction (apnea) or reduced airflow (hypopnoea) despite persistent respiratory effort. Apnea is defined as the cessation of breathing for at least 10 seconds during sleep, while hypopnoea is defined as at least 30% reduction in airflow for 10 seconds associated with oxygen desaturation and sleep fragmentation. The presence in the general population is about 4%. The principal symptoms are: excessive daytime sleepiness (EDS), snoring, dry throat, morning headache, night sweats, gastro-esophageal reflux, and increased blood pressure.Long term complications can be: increased cardio-cerebrovascular risk and cognitive impairment such as deficiency in attention, vigilance, visual abilities, thought, speech, perception and short term memory.Continuous Positive Airway Pressure (CPAP) is currently the best non-invasive therapy for OSAS.CPAP guarantees the opening of upper airways using pulmonary reflexive mechanisms increasing lung volume during exhalation and resistance reduction, decreasing electromyografical muscular activity around airways.The causes of cognitive impairments and their possible reversibility after CPAP treatment have been analysed in numerous studies. The findings, albeit controversial, show that memory, attention and executive functions are the most compromised cognitive functions.The necessity of increasing the patient compliance with ventilotherapy is evident, in order to prevent cognitive deterioration and, when possible, rehabilitate the compromised functions, a difficult task for executive functions

Increased oral nitric oxide in obstructive sleep apnoea

SummaryBackgroundHypoxia and snoring-related mechanical trauma contribute to airway inflammation in obstructive sleep apnoea (OSA). Increased exhaled nitric oxide (FENO), an airway inflammation marker, has been reported in OSA patients. We propose the measure of NO in the oral cavity (oNO) as marker of oropharyngeal inflammation in OSA.MethodsWe compared oNO and FENO of 39 OSA patients with those of 26 mild asthmatics (ASTHMA), 15 patients with chronic rhinitis or rhinosinusitis (CRS) and 24 healthy subjects. A special device was used for oNO measurement. Apnoea/hypopnoea index (AHI), oxygen desaturation index, mean and nadir SaO2 were calculated from the polysomnography.ResultsoNO was significantly increased in OSA (104.2 95%CI 80.2–135.5ppb) as compared to ASTHMA (71.9 95%CI 56.3–91.9ppb; p=0.015), CRS (54.4 95%CI 40.2–73.7ppb; p=0.009) and healthy subjects (63.6 95%CI 59–73ppb; p<0.001). oNO was directly related to AHI (r=0.466, p=0.003) and to minutes slept with SaO2 <90% (r=0.471, p=0.011) and it was inversely related to nadirSaO2 (r=−0.393, p=0.018). FENO was highest in asthmatics (40.3 95%CI 32.5–50.1ppb) and only slightly elevated in OSA (23.1 95%CI 19,8–28.3ppb) and CRS (22.8 95%CI 16.8–32.5ppb).ConclusionsThe finding that oral NO is increased in OSA and is related to upper airway obstructive episodes and to hypoxemia severity, strengthens the clinical and pathogenic role of oral inflammation in OSA