Gender differences in sleep disorders in the US military

The article of record as published may be found at http://dx.doi.org/10.1016/j.sleh.2017.07.015Objectives: The purpose of this study is to compare sleep disorders between male and female military personnel. Comorbid behavioral health disorders and chronic pain were also studied in relation to sleep disorders. Design: We conducted a retrospective review of military personnel who underwent a sleep medicine evaluation and an in-laboratory attended polysomnography. Initial sleep questionnaires, demographics, polysomnographic variables, and comorbid disorders of interest were reviewed and compared for each sex. Setting: All patients were referred to the Wilford Hall Ambulatory Surgical Center Sleep Disorders Center for evaluation of sleep disturbance. Participants: Our cohort consisted of 209 military personnel with 51.7% men. The cohort was relatively young with a mean age of 34.3 years. Men had a significantly higher body mass index at 29.4 vs 27.3 in women. Results: Insomnia was diagnosed in 72 women and 41 men (P b .001), whereas obstructive sleep apnea (OSA) was diagnosed in 92 men and 50 women (P b .001). Depression and anxiety were more common in women. Women had an average of 1.76 ± 1.36 comorbid conditions compared with 1.08 ± 1.19 in men. In patients diagnosed with both insomnia and OSA, women were more likely to have post-traumatic stress disorder, depression, and anxiety. Neither the Epworth Sleepiness Scale (12.8 ± 4.88) nor the Insomnia Severity Index (16.9 ± 5.33) differed between sexes. Conclusions: Gender-related differences in sleep disorders are present in active-duty personnel. Behavioral health disorders were frequent comorbid disorders, and women diagnosed with both insomnia and OSA manifested greater psychiatric comorbidity. The frequent association between sleep and behavioral health disorders in military personnel requires further study

An Initial Report of Sleep Disorders in Women in the U.S. Military

The article of record as published may be found at http://dx.doi.org/10.1093/milmed/usx116Sleep disorders are increasingly recognized in active duty service members (ADSM). While there are multiple studies in male ADSM, there are limited data regarding sleep disorders in women in the military. The purpose of this study was to characterize sleep disorders in female ADSM referred for clinical evaluation to provide a better understanding of this unique population. Materials and Methods: We conducted a retrospective review of female ADSM who underwent a sleep medicine evaluation and an attended polysomnogram (PSG). Demographic and polysomnogram variables, as well as medical records, were reviewed. Associated illnesses to include post-traumatic stress disorder, pain disorders, anxiety, and depression, were recorded. Results: The cohort consisted of 101 women. The average age was 33.9 ± 9.0 years and body mass index was 27.3 ± 4.5, with an average Epworth Sleepiness Scale score of 12.9 ± 5.2, and Insomnia Severity Index score of 17.6 ± 5.7. Overall, 36.6% were diagnosed with insomnia only, 14.9% with obstructive sleep apnea (OSA) only, and 34.7% met diagnostic criteria for both insomnia and OSA. The average apnea-hypopnea index for the entire cohort was 5.37 ± 7.04/h whereas it was 10.34 ± 3.14/h for those meeting diagnostic criteria for OSA. The women referred for sleep evaluations had the following rates of associated illnesses: pain disorders (59.4%), anxiety (48.5%), depression (46.5%), and post-traumatic stress disorder (21.8%). For patients with OSA, the relative risk of having post-traumatic stress disorder was 2.72 (95% confidence interval 1.16–6.39). Conclusions: Women in the U.S. military who have sleep disorders have a high rate of behavioral medicine and pain disorders. Interestingly, nearly 50% of active duty females referred for a sleep study have OSA while not necessarily manifesting the typical signs of obesity or increased age. The reasons for this finding are not completely understood, though factors related to military service may potentially contribute. The findings from our study indicate a need for increased awareness and evaluation of sleep disorders in women in the military, especially those with behavioral medicine disorders

Elevated tau and interleukin-6 concentrations in adults with obstructive sleep apnea

The article of record as published may be found at http://dx.doi.org/10.1016/j.sleep.2017.11.1121Obstructive sleep apnea (OSA) is characterized by apneas and hypopneas that result in hypoxia, cerebral hypoperfusion, endothelial dysfunction, inflammation, and oxidative stress. These pathophysiologic processes likely contribute to neuronal damage. Tau is a protein that stabilizes microtubules and, along with amyloid beta (Ab), is associated with neurodegenerative processes. We sought to determine if tau and other biomarkers of inflammation were related to OSA severity. Concentrations of tau, Ab40, Ab42, c-reactive protein (CRP), TNF-a, interleukin (IL)-6, and IL-10 were measured in blood and compared between participants with moderate-severe OSA (n 1⁄4 28), those with mild OSA (n 1⁄4 22), and healthy controls (n 1⁄4 24). The cohort included relatively young, primarily male active duty military personnel without a history of traumatic brain injury or neurodegenerative disease. Total biomarker concentrations were determined from plasma samples using an ultra-sensitive detection method, SimoaTM, and CRP was assayed by ELISA. Total tau and IL-6 concentrations were elevated in participants with moderate-severe OSA, with a mean apnea-hypopnea index (AHI) of 26.1/h, compared to those with mild OSA (mean AHI 8.6/h) and healthy controls (mean AHI 2.1/h). Tau concentrations were also significantly correlated with the AHI (r 1⁄4 0.342, p 1⁄4 0.004). Our findings show that tau is elevated in the blood of young patients with moderate-severe OSA, suggesting that this degree of sleep-disordered breathing is a contributing factor in the development of neurodegenerative disorders. The finding of increased IL-6 further suggests that inflammatory biomarkers are present early in the course of this chronic disease

Military personnel with chronic symptoms following blast traumatic brain injury have differential expression of neuronal recovery and epidermal growth factor receptor genes

Objective: Approximately one-quarter of military personnel who deployed to combat stations sustained one or more blast-related, closed-head injuries. Blast injuries result from the detonation of an explosive device. The mechanisms associated with blast exposure that give rise to traumatic brain injury (TBI), and place military personnel at high risk for chronic symptoms of post-concussive disorder (PCD), post-traumatic stress disorder (PTSD), and depression are not elucidated. Methods: To investigate the mechanisms of persistent blast-related symptoms, we examined expression profiles of transcripts across the genome to determine the role of gene activity in chronic symptoms following blast-TBI. Active duty military personnel with (1) a medical record of a blast-TBI that occurred during deployment (n = 19) were compared to control participants without TBI (n = 17). Controls were matched to cases on demographic factors including age, gender, and race, and also in diagnoses of sleep disturbance, and symptoms of PTSD and depression. Due to the high number of PCD symptoms in the TBI+ group, we did not match on this variable. Using expression profiles of transcripts in microarray platform in peripheral samples of whole blood, significantly differentially expressed gene lists were generated. Statistical threshold is based on criteria of 1.5 magnitude fold-change (up or down) and p-values with multiple test correction (false discovery rate \u3c0.05). Results: There were 34 transcripts in 29 genes that were differentially regulated in blast-TBI participants compared to controls. Up-regulated genes included epithelial cell transforming sequence and zinc finger proteins, which are necessary for astrocyte differentiation following injury. Tensin-1, which has been implicated in neuronal recovery in pre-clinical TBI models, was down-regulated in blast-TBI participants. Protein ubiquitination genes, such as epidermal growth factor receptor, were also down-regulated and identified as the central regulators in the gene network determined by interaction pathway analysis. Conclusion: In this study, we identified a gene-expression pathway of delayed neuronal recovery in military personnel a blast-TBI and chronic symptoms. Future work is needed to determine if therapeutic agents that regulate these pathways may provide novel treatments for chronic blast-TBI-related symptoms

Leaning in to Address Sleep Disturbances and Sleep Disorders in Department of Defense and Defense Health Agency

Letter to the Editor, Military Medicine, 187, 5/6:155, 202217 USC 105 interim-entered record; under review.The article of record as published may be found at http://dx.doi.org/10.1177/0018720820906050In their article entitled, “Engaging Stakeholders to Optimize Sleep Disorders Management in the U.S. Military: A Qualitative Analysis,” Abdelwadoud and colleagues conducted focus groups of service members, primary care managers (PCMs), and administrative stakeholders about their perceptions, experiences, roles in sleep management, stated education needs, and management of sleep disorders.1 The qualitative methods are rigorous, and the findings reinforce and nuance prior results, especially regarding key requirements from PCMs. We feel compelled, however, to further nuance the authors’ conclusion that “current military sleep management practices are neither satisfactory nor maximally effective” and offer specific examples of actions taken by the Department of Defense (DoD) and Defense Health Agency (DHA) in recognition of the significance of optimal sleep in combat readiness and overall health of service members. We offer here a succinct list of concrete efforts to support and implement substantial clinical, operational, research, or educational efforts by the DoD or DHA to improve sleep in service members and associated clinical challenges in this unique population.Identified in text as U.S. Government work

Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health

The article of record as published may be found at http://dx.doi.org/10.1093/sleep/zsab161Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: 1) a recognition of the factors contributing to fatigue and fatigue-related risks; 2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and 3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.Academy of Sleep Medicine (AASM)Sleep Research Societ

An unusual circadian rhythm in an active duty service member

The article of record as published may be found at http://dx.doi.org/10.1007/s41105-015-0003-0The case of a 29-year-old active duty US Navy sailor with severe sleepiness is presented. He was diagnosed with mild obstructive sleep apnea which did not fully explain his sleepiness. At follow-up, positive airway pressure usage demonstrated a progressive, variable phase delay. His sleep periods aligned with his 5-h on/10-h off (5/10) military duty schedule. Treatment with bright light exposure and melatonin resolved his circadian arrhythmia. While it is known that military personnel are habitual shift workers who receive insufficient sleep, there is little documentation of shift work disorders in this population

Nightmares in United States Military Personnel With Sleep Disturbances

The article of record as published may be found at http://doi.org/10.5664/jcsm.6990The spectrum of sleep disorders in military personnel is varied and complicated by the presence of comorbidities and psychological disorders. Currently, little is known regarding nightmares, especially trauma-related nightmares. Study Impact: This is the first study to report on objective and subjective sleep attributes in a cohort of military personnel, determining the prevalence of nightmares and polysomnographic characteristics associated with nightmares. Clinically, this highlights the need for military and civilian health care providers to evaluate for nightmares in individuals with sleep disturbances after traumatic experiences. From a research perspective, these findings provide the basis to further address nightmares, which are associated with the pressing issues of sleep and behavioral medicine disorders and suicidality in military and veteran populations

Adherence to Positive Airway Pressure Therapy in U.S. Military Personnel With Sleep Apnea Improves Sleepiness, Sleep Quality, and Depressive Symptoms

Objectives: Obstructive sleep apnea (OSA) is frequently diagnosed in U.S. military personnel. OSA is associated with sleepiness, poor sleep quality, and service-related illnesses of insomnia, depression, post-traumatic stress disorder, and traumatic brain injuryThis study was supported, in part, by grant no. 60855 from the Center for Neuroscience and Regenerative Medicine

The Veterans Administration and Department of Defense clinical practice guidelines for the diagnosis and management of sleep disorders: what does this mean for the practice of sleep medicine?

In 2017 the Veterans Administration (VA) and Department of Defense (DOD) launched development of clinical practice guidelines (CPGs) for the diagnosis and treatment of sleep disorders, with the goal of informing and improving patient care. The guideline development process followed GRADE methodology, considering studies and systematic reviews published over the 10-year period prior to guideline development. A total of 41 recommendations were made,18 related to the diagnosis and treatment of obstructive sleep apnea (OSA) and 23 regarding chronic insomnia disorder. In contrast to other published guidelines, the VA DoD CPGs provide a comprehensive approach to diagnosis and management of the two most common sleep disorders, including a discussion of the sequencing of diagnostic approaches and treatment options. Regarding OSA, strong recommendations were made for follow-up evaluation after non-diagnostic home sleep apnea tests, positive airway pressure therapy as first-line treatment, and the incorporation of supportive, educational and behavioral interventions for patients at high risk for PAP therapy non-adherence due to comorbid conditions. Strong recommendations were also made for the use of cognitive-behavioral therapy for insomnia and against the use of kava (an herbal supplement) in the treatment of chronic insomnia disorder. These guidelines, while intended to directly inform care within VA and DOD, are broadly relevant to the practice of sleep medicine. The majority of scientific evidence was based on studies of non-military, non-veteran populations. The CPG is a major milestone for the VA and DOD in recognizing the importance of evidence-based treatments for sleep disorders in military personnel and veterans