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

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

Clinical characteristics of a large cohort of patients with narcolepsy candidate for pitolisant: a cross-sectional study from the Italian PASS Wakix® Cohort

Introduction Narcolepsy is a chronic and rare hypersomnia of central origin characterized by excessive daytime sleepiness and a complex array of symptoms as well as by several medical comorbidities. With growing pharmacological options, polytherapy may increase the possibility of a patient-centered management of narcolepsy symptoms. The aims of our study are to describe a large cohort of Italian patients with narcolepsy who were candidates for pitolisant treatment and to compare patients' subgroups based on current drug prescription (drug-naive patients in whom pitolisant was the first-choice treatment, switching to pitolisant from other monotherapy treatments, and adding on in polytherapy). Methods We conducted a cross-sectional survey based on Italian data from the inclusion visits of the Post Authorization Safety Study of pitolisant, a 5-year observational, multicenter, international study. Results One hundred ninety-one patients were enrolled (76.4% with narcolepsy type 1 and 23.6% with narcolepsy type 2). Most patients (63.4%) presented at least one comorbidity, mainly cardiovascular and psychiatric. Pitolisant was prescribed as an add-on treatment in 120/191 patients (62.8%), as switch from other therapies in 42/191 (22.0%), and as a first-line treatment in 29/191 (15.2%). Drug-naive patients presented more severe sleepiness, lower functional status, and a higher incidence of depressive symptoms. Conclusion Our study presents the picture of a large cohort of Italian patients with narcolepsy who were prescribed with pitolisant, suggesting that polytherapy is highly frequent to tailor a patient-centered approach