Search

Trauma associated sleep disorder is a proposed parasomnia that develops after trauma with clinical features of trauma related nightmares, disruptive nocturnal behaviors, and autonomic disturbances. The purpose of this case series is to better characterize the clinical and video-polysomnographic features of patients meeting clinical criteria for this proposed parasomnia.Semistructured clinical interview and detailed video-polysomnography review of 40 patients. Movements and vocalizations in rapid eye movement sleep were quantified according to the rapid eye movement sleep behavior disorder severity scale.Patients (n = 40, 32 males) were service members and veterans with a median age of 38.9 years (range 24-57 years) who reported trauma related nightmares and disruptive nocturnal behaviors at home. On video-polysomnography, 28 (71.8%) patients had disruptive nocturnal behaviors in rapid eye movement sleep consisting of limb, head, and axial movements; vocalizations were present in 8 (20%). On the rapid eye movement sleep behavior disorder severity scale, most (n = 28, 71.8%) had a low rating but those with greater severity (n = 11, 28.2%) had a higher prevalence of posttraumatic stress disorder (Disruptive nocturnal behaviors can be captured on video-polysomnography during rapid eye movement sleep, although they may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-polysomnographic correlations are invaluable in assessing patients with trauma associated sleep disorder to document objective abnormalities. This case series provides a further basis for establishing trauma associated sleep disorder as a unique parasomnia.Brock MS, Matsangas P, Creamer JL, et al. Clinical and polysomnographic features of trauma associated sleep disorder.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is increasingly common among military personnel, but diagnostic capabilities are challenged by limited capability for polysomnography (PSG). We sought to evaluate the diagnostic properties of peripheral arterial tonometry (PAT)–based home sleep apnea testing (HSAT) to accurately identify and classify OSA among active-duty military personnel. METHODS: This study was a retrospective review of all patients suspected of having OSA who completed an initial PAT-based HSAT followed by confirmatory PSG within 120 days. The diagnostic properties of a PAT-based, HSAT-derived apnea-hypopnea index (AHI) vs a PSG-derived AHI were assessed. RESULTS: Two hundred eight matched pairs of asynchronous studies were analyzed. The prevalence of OSA was 63.5%. PAT-based HSAT overdiagnosed 27.4% of patients with OSA and underdiagnosed 46.6% of patients with OSA. The majority (n = 116, 55.8%) of patients changed OSA severity classification (absent, mild, moderate, severe) after PSG. OSA severity classification concordance between PAT-based HSAT and PSG was observed in 53.4%, 40.5%, 28.6%, and 40.0% of patients with absent, mild, moderate, and severe OSA, respectively. Receiver operating characteristic curve analysis showed an area under the curve of 0.715 and a proposed PAT-based, HSAT-derived AHI cutoff score for OSA diagnosis of 9.0 events/h. This PAT-based, HSAT-derived AHI provided a 52% sensitivity, 83% specificity, 84% positive predictive value, and 50% negative predictive value. Bland-Altman plots showed an unacceptable degree of agreement between PAT-based, HSAT-derived AHI and AHI. CONCLUSIONS: There is significant discordance between PAT-based HSAT and PSG among active-duty military personnel evaluated for OSA. PAT-based HSAT may have limited utility for diagnosing OSA and grading severity in this unique patient population. CITATION: O’Reilly BM, Wang Q, Collen J, Matsangas P, Colombo CJ, Mysliwiec V. Performance comparison of peripheral arterial tonometry–based testing and polysomnography to diagnose obstructive sleep apnea in military personnel. J Clin Sleep Med. 2022;18(6):1523–1530.

Study objectives. Women who experienced childhood sexual abuse have higher rates of obesity, a risk factor for obstructive sleep apnea (OSA). We assessed if prior childhood sexual abuse was more common in women with OSA vs. control, with possible mediation by obesity. Methods. We studied 21 women with OSA (age mean±s.d. 59±12 years, body mass index (BMI) 33±8 kg/m2, respiratory event index [REI] 25±16 events/hour, Epworth Sleepiness Scale [ESS] 8±5) and 21 women without OSA (age 53±9 years, BMI 25±5 kg/m2, REI (in 7/21 women) 1±1 events/hour, ESS 5±3). We evaluated four categories of trauma (general trauma, physical, emotional, and sexual abuse) with the early trauma inventory self-report-short form (ETISR-SF). We assessed group differences in trauma scores with independent samples t-tests and multiple regressions. Parametric Sobel tests were used to model BMI as a mediator for individual trauma scores predicting OSA in women. Results. Early childhood sexual abuse reported on the ETISR-SF was 2.4 times more common in women with vs. without OSA (p=0.02 for group difference). Other trauma scores were not significantly different between women with and without OSA. However, BMI was a significant mediator (p=0.02) in predicting OSA in women who experienced childhood physical abuse. Conclusions. Childhood sexual abuse was more common in a group of women with OSA than those without OSA. Additionally, BMI was a mediator for OSA of childhood physical but not sexual abuse. There may be physiological impacts of childhood trauma in women that predispose them to OSA.

Introduction The incidence of nightmares and dreams during clinically indicated polysomnography (PSG) is rarely reported. We sought to (1) describe the incidence of nightmares and dreams during PSG, (2) PSG characteristics of nightmares and dreams, and (3) identify clinical correlates. Methods Ninety-three patients undergoing an initial clinically indicated PSG had a post-PSG and initial intake questionnaire reviewed. Questionnaires included Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI) and Nightmare Disorder Index (NDI), as well as a structured post-PSG dreams and nightmares questionnaire. Dreams were self-reported, and a nightmare was differentiated from a bad dream if the former caused a patient-reported awakening. Results Overall, 87.1% were Active Duty and 89.2% reported the presence or absence of dreams. In total, 50.5% (47) reported no dreams, 22.6% (21) reported a dream, 2.2% (2) a bad dream, and 14% (13) a nightmare with 12/13 reporting details of their nightmare. The mean total NDI differed significantly between groups (6 ± 5 vs. 7 ± 6 vs. 12 ± 0 vs. 11 ± 5, respectively) (p=0.029). The groups were not significantly different based on sex, age, BMI, diagnosis of depression, anxiety, PTSD, TBI, chronic pain, being prescribed a sleep aid or psychoactive medication, or their ESS and ISI values. PSG characteristics including REM percentage did not differ significantly between groups. Of those reporting a nightmare 75% (9) reported associated autonomic symptoms and 5 (41.7%) reported a trauma related nightmare (TRN). Of those with a TRN, one was related to combat, one sexual assault, two an accident, and one related to death. Two patients with TRN reported their nightmare was an accurate replay of the trauma, 2 reported a mix of replay/non-replay events, and one did not answer. Conclusion Despite rare reports of nightmare capture in sleep labs, our cohort uniquely demonstrated that at least half of first time PSG patients at a military sleep center experience a dream or nightmare during their PSG. Higher NDI scores may predict who is more likely to suffer from a bad dream or nightmare in the sleep lab. Assessing for the occurrence of dreams or nightmares during PSG is likely indicated. Support (if any)

The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary function remain unclear. Cardiorespiratory fitness (CRF), commonly reflected by VO(2) max measured during cardiopulmonary exercise testing, has gained popularity in evaluating numerous cardiopulmonary conditions and may provide a novel means of identifying OSA patients with the most clinically significant disease. This emerging testing modality provides simultaneous assessment of respiratory and cardiovascular function with results helping uncover evidence of evolving pathology in either organ system. In this review, we highlight the current state of the literature in regard to OSA and CRF with a specific focus on changes in cardiovascular function that have been previously noted. While OSA does not appear to limit respiratory function during exercise, studies seem to suggest an abnormal cardiovascular exercise response in this population including decreased cardiac output, a blunted heart rate response (ie, chronotropic incompetence), and exaggerated blood pressure response. Surprisingly, despite these observed changes in the cardiovascular response to exercise, results involving VO(2) max in OSA remain inconclusive. This is reflected by VO(2) max studies involving middle-aged OSA patients showing both normal and reduced CRF. As prior studies have not extensively characterized oxygen desaturation burden, we propose that reductions in VO(2) max may exist in OSA patients with only the most significant disease (as reflected by nocturnal hypoxia). Further characterizing this relationship remains important as some research suggests that positive airway pressure therapy or aerobic exercise may improve CRF in patients with OSA. In conclusion, while it likely that severe OSA, via an abnormal cardiovascular response to exercise, is associated with decreased CRF, further study is clearly warranted to include determining if OSA with decreased CRF is associated with increased morbidity or mortality. CITATION: Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med. 2022;18(1):279–288.

Study Objectives The aim of this study was to characterize the sleep disorders of insomnia, obstructive sleep apnea (OSA), and comorbid insomnia and OSA (COMISA) in active duty military personnel. Methods Prospective observational study of 309 military personnel with a mean age of 37.17 years (SD = 7.27). Participants served in four branches of the U.S. military (47.9% Air Force, 38.8% Army, 11.3% Navy, and 1.9% Marines). Sleep diagnoses were rendered after video-polysomnography and a clinical evaluation. Validated self-report measures assessed insomnia severity, excessive daytime sleepiness, sleep quality, disruptive nocturnal behaviors, nightmare disorder, shift work disorder (SWD), sleep impairment, fatigue, posttraumatic stress disorder (PTSD) symptoms, anxiety, depression, and traumatic brain injury (TBI). General linear models and Pearson chi-square tests were used for between-group differences in data analyses. Results Insomnia was diagnosed in 32.7%, OSA in 30.4% and COMISA in 36.9%. Compared to military personnel with OSA alone, those with insomnia only and COMISA had significantly greater insomnia severity, disruptive nocturnal behaviors, sleep-related impairment, rates of nightmare disorder, and poorer sleep quality (all Ps < .05). They also reported greater symptoms of fatigue, PTSD, anxiety, and depression (all Ps < .05). There were no significant differences among the three sleep disorder diagnostic groups on sleepiness, SWD, or TBI. Conclusions Military personnel with insomnia only and COMISA overall report worsened symptoms of sleep disorders, sleep-related impairment, fatigue, and psychiatric disorders than those with OSA. Results highlight the importance of a comprehensive assessment for sleep-related impairment, sleep, and comorbid disorders in military personnel with clinically significant sleep disturbances.

Introduction The incidence and clinical significance of nightmares is difficult to estimate due to varying criteria across studies. The Nightmare Disorder Index (NDI) is a validated measure to evaluate nightmare disorder. However, there is no measure to differentiate trauma-related nightmares compared to trauma associated sleep disorder (TSD), a unique REM parasomnia. The objectives of this study were to (1) determine the incidence of nightmare disorder and TSD in patients referred for a clinically indicated sleep evaluation, and (2) further characterize TSD. Methods All initial sleep referrals completed intake questionnaires including validated measures such as the NDI, Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI). Patients who endorsed at least weekly nightmares related to trauma, with vocalizations or disruptive nocturnal behaviors, and autonomic surges additionally received a structured clinical interview focusing on thematic content of dreams, dream enactment behavior, self-reported symptoms of autonomic hyperactivity, and, if previously treated, nightmare severity before and after therapy. Results 102 new patients completed the NDI and 56.9% (58) met criteria for probable nightmare disorder (ND). Of the 58 patients with probable ND, 13.8% (8) had symptoms consistent with TSD (7.8% of new referrals). Compared to ND patients, TSD patients were more likely to have higher ISI (24.0 ± 3.0 vs. 18.6 ± 5.6) (p=0.023) and total NDI score (15.8 ± 3.5 vs. 10.0 ± 3.7) (p< 0.001), but not ESS (p=0.158). Structured interview revealed all TSD patients had significant daytime distress or impairment. The nature of trauma was combat for 3 individuals, physical assault for 1, and sexual assault for 4 (one occurring while deployed). All individuals reported tachycardia secondary to nightmares and tachypnea and diaphoresis were each reported in 75% of patients. Regarding dream content, 25% endorsed accurate replay of trauma, 25% related to trauma but non-replay, and 50% mixed. For DNB, 87.5% of patients endorsed vocalization (moaning, screaming, or yelling), 87.5% endorsed movements (tossing, turning, or thrashing), and 37.5% endorsed combative behaviors (striking of bed partner). Conclusion This study reports a surprisingly high incidence of probable ND among all new sleep medicine patients. TSD appears to be a clinically distinct, more severe parasomnia compared to ND. Support (if any)

Introduction Women constitute approximately 17% of the military. Yet, relatively little is known regarding sleep disorders and comorbid diagnoses effecting this gender. The aim of this study was to determine if there were gender-related differences in symptoms of sleep disorders and sleep-related impairment, comorbid sleep, behavioral medicine, and traumatic brain injury (TBI) diagnoses and polysomnographic (PSG) variables in military personnel with insomnia, OSA, and comorbid insomnia and OSA (COMISA). Methods Participants were 372 military personnel (46.2% females, 53.8% males) with an average age of 37.7±7.46 years and median BMI of 28.4 (5.50) kg/m2. Based on clinical evaluation and video-PSG, participants were diagnosed with insomnia (n = 118, 71.2% female), OSA (n = 118, 28.8% female) and COMISA (n = 136, 39.7% female). Insomnia severity, excessive daytime sleepiness, sleep quality, nightmare disorder, sleep impairment, fatigue, posttraumatic stress disorder (PTSD), anxiety, depression symptoms, and traumatic brain injury (TBI) were evaluated with validated questionnaires. Descriptive statistics, parametric and non-parametric pairwise comparisons and effect-size analyses were used to assess differences between sexes in terms of variables of interest. Results Female service members had significantly greater symptoms of nightmare disorder, PTSD, anxiety, and depression than their male counterparts. There were no significant differences between males and females with insomnia or OSA in sleep-related symptoms, impairment, or PSG based apnea-hypopnea index (AHI). Male service members with COMISA had a significantly greater AHI; females with COMISA had significantly greater symptoms of nightmare disorder, PTSD and anxiety. Conclusion In the largest study to date to clinically evaluate sleep disorders in military personnel, COMISA was the most frequent diagnosis. Surprisingly, there were minimal differences in self-reported symptoms of sleep disorders and PSG characteristics. However, male servicemembers with COMISA have more severe sleep disordered breathing while female servicemembers with COMISA have greater mental health morbidity. Military service may result in distinct sleep disorder phenotype(s). Support (if any) This work was supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health (DM170708; Mysliwiec) and the US Air Force (USAF) Air Force Materiel Command (AFMC), Wright Patterson Air Force Base, Ohio (FA8650-18-2-6953; Peterson).

ObjectiveTo test the hypothesis that reduced slow-wave sleep, or N3 sleep, which is thought to underlie the restorative functions of sleep, is associated with MRI markers of brain aging, we evaluated this relationship in the community-based Framingham Heart Study Offspring cohort using polysomnography and brain MRI.MethodsWe studied 492 participants (age 58.8 ± 8.8 years, 49.4% male) free of neurological diseases who completed a brain MRI scan and in-home overnight polysomnography to assess slow-wave sleep (absolute duration and percentage of total sleep). Volumes of total brain, total cortical, frontal cortical, subcortical gray matter, hippocampus, and white matter hyperintensities were investigated as a percentage of intracranial volume, and the presence of covert brain infarcts was evaluated. Linear and logistic regression models were adjusted for age, age squared, sex, time interval between polysomnography and MRI (3.3 ± 1.0 years), APOE ε4 carrier status, stroke risk factors, sleeping pill use, body mass index, and depression.ResultsLess slow-wave sleep was associated with lower cortical brain volume (absolute duration, β [standard error] = 0.20 [0.08], p = 0.015; percentage, 0.16 [0.08], p = 0.044), lower subcortical brain volume (percentage, 0.03 [0.02], p = 0.034), and higher white matter hyperintensities volume (absolute duration, −0.12 [0.05], p = 0.010; percentage, −0.10 [0.04], p = 0.033). Slow-wave sleep duration was not associated with hippocampal volume or the presence of covert brain infarcts.ConclusionLoss of slow-wave sleep might facilitate accelerated brain aging, as evidence by its association with MRI markers suggestive of brain atrophy and injury. Alternatively, subtle injuries and accelerated aging might reduce the ability of the brain to produce slow-wave sleep.

Introduction Insomnia and obstructive sleep apnea are common conditions among military service members, with high rates of comorbidity. Although cognitive behavioral therapy for insomnia (CBT-I) has been established as an effective treatment for insomnia, it is unclear whether or not CBT-I is effective among service members with comorbid insomnia and obstructive sleep apnea. Materials and Methods This retrospective, observational study examined insomnia outcomes among a group of service member patients (N = 73) with comorbid insomnia and obstructive sleep apnea. All patients received individual CBT-I in a specialty sleep clinic at a military treatment facility. Seven outcomes associated with insomnia were evaluated before and after treatment. Results On average, patients showed significant improvement in sleep onset latency, wake after sleep onset, sleep efficiency, number of awakenings, and symptoms reported on the Insomnia Severity Index. Twenty-six percent of patients showed clinically significant improvement in reported insomnia symptoms. Conclusions These results suggest that CBT-I may be effective in treating military service members with comorbid insomnia and obstructive sleep apnea. Despite the limitations of data collected in a clinical setting, consistent findings across five of the seven outcome measures provide good evidence that this treatment can be implemented in military settings.

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. CITATION: Martin JL, Mysliwiec V, Chowdhuri S, Ulmer CS. 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? J Clin Sleep Med. 2020;16(8):1377–1381.

While forehead cooling has been studied in patients with insomnia in the absence of comorbid medical/psychiatric disorders, it has never been evaluated in patients with insomnia in the presence of co-morbid medical/psychiatric disorders. Veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions received 4-week open-label, in-home, nightly treatment with a forehead cooling device (14–16 °C) along with personalized sleep hygiene following baseline assessments. Pre- and post-treatment, participants completed the Insomnia Severity Index (ISI), the Generalized Anxiety Disorder 7-item scale (GAD-7), and the Patient Health Questionnaire 9-item scale (PHQ-9). Participants recorded daily sleep and anxiety/arousal symptoms. Of 24 veterans (20 men, 42.2 ± 9.5 years), 17 (71%) had marked insomnia severity improvement (a decrease of > 8 on the ISI) and 10 (42%) participants scored 7 or below on the ISI at post-treatment reflecting remission. Participants reported reductions in sleep onset latency (SOL) (F = 12.9, p < 0.001), and wakefulness after sleep onset (WASO) (F = 8.4, p < 0.001) across treatment. They also had significant reductions in insomnia severity (t = 10.04, p < 0.001), anxiety (t = 3.59, p = 0.002), and depression (t = 7.75, p < 0.001) from pre- to post-treatment. This pilot study shows that 4-week nightly use of a forehead cooling device produces improvements in insomnia, anxiety, and depressive symptoms in veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions. Controlled studies are warranted to determine the role of this therapy in the management of insomnia in veterans. Not required as a small sample size feasibility study.

Description In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. Methods In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

To our knowledge, no studies on health conditions in U.S. military firefighters exist. Data and demographics from the Defense Medical Epidemiology Database were analyzed on several shared medical issues among military personnel and civilian firefighters. Descriptive statistics and Chi-Square goodness of fit tests were conducted to support study aims. Between 2001 and 2015, substantial incidence rate increases (per 10,000) of tinnitus, PTSD, insomnia, and OSA (2005–2015) were observed. Modest to large increases in depressive disorders, adjustment reaction, generalized anxiety disorder, and panic disorder were observed. Decreasing rates were observed for alcohol dependence, hypertension, and tobacco use disorder. While efforts have examined the impact of sustained operations on military members, first responder military subgroups like firefighters are deficient. Cognitive Behavior Therapy interventions are efficacious for preventing and reducing behavioral health problems; therefore, tailoring them specifically for U.S. military firefighters could significantly improve quality of life and long-term health.

Letter to the Editor, Military Medicine, 187, 5/6:155, 2022 17 USC 105 interim-entered record; under review. The article of record as published may be found at http://dx.doi.org/10.1177/0018720820906050 In 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.

Mild traumatic brain injuries (mTBI) are a pervasive concern for military personnel. Determining the impact of injury severity, including loss of consciousness (LOC) may provide important insights into the risk of psychological symptoms and inflammation commonly witnessed in military personnel and veterans following mTBI. US military personnel and veterans were categorized into three groups; TBI with LOC (n = 36), TBI without LOC (n = 25), Controls (n = 82). Participants reported their history of mTBI, psychological symptoms (post-traumatic stress disorder [PTSD] and depression), health-related quality of life (HRQOL), and underwent a blood draw. ANCOVA models which controlled for insomnia status and combat exposure indicated that both mTBI groups (with/without LOC) reported significantly greater depression and PTSD symptoms compared to controls; however, they did not differ from each other. The mTBI with LOC did report greater pain than both controls and mTBI without LOC. The TBI with LOC group also had significantly elevated IL-6 concentrations than both TBI without LOC and control groups. Within the mTBI groups, increased TNFα concentrations were associated with greater PTSD symptoms. These findings indicate that sustaining an mTBI, with or without LOC is detrimental for psychological wellbeing. However, LOC may be involved in perceptions of pain and concentrations of IL-6.

Study Objectives:Studies of older and less active patients with obstructive sleep apnea (OSA) have reported decreased exercise capacity as measured by peak oxygen uptake (VO2 max) during cardiopulm...

The military lifestyle often includes continuous operations whether in training or deployed environments. These stressful environments present unique challenges for service members attempting to achieve consolidated, restorative sleep. The significant mental and physical derangements caused by degraded metabolic, cardiovascular, skeletomuscular, and cognitive health often result from insufficient sleep and/or circadian misalignment. Insufficient sleep and resulting fatigue compromises personal safety, mission success, and even national security. In the long-term, chronic insufficient sleep and circadian rhythm disorders have been associated with other sleep disorders (e.g., insomnia, obstructive sleep apnea, and parasomnias). Other physiologic and psychologic diagnoses such as post-traumatic stress disorder, cardiovascular disease, and dementia have also been associated with chronic, insufficient sleep. Increased co-morbidity and mortality are compounded by traumatic brain injury resulting from blunt trauma, blast exposure, and highly physically demanding tasks under load. We present the current state of science in human and animal models specific to service members during- and post-military career. We focus on mission requirements of night shift work, sustained operations, and rapid re-entrainment to time zones. We then propose targeted pharmacological and non-pharmacological countermeasures to optimize performance that are mission- and symptom-specific. We recognize a critical gap in research involving service members, but provide tailored interventions for military health care providers based on the large body of research in health care and public service workers.

Patients with obstructive sleep apnea (OSA) commonly report residual excessive daytime sleepiness (EDS) despite treatment with positive airway pressure (PAP). The present study aimed to determine whether patients presenting with subjective sleepiness after treatment with PAP therapy had objective evidence of residual sleepiness.We conducted a retrospective analysis of 29 adults with OSA on PAP therapy who underwent a standardized evaluation for EDS. Patients were evaluated with the Epworth Sleepiness Scale (ESS) and attend an in-lab polysomnogram (PSG) with PAP followed by a multiple sleep latency test (MSLT).Our cohort consisted of 23 men (79%) and 6 women (21%) with a mean age of 40.7 years. All patients were subjectively sleepy with an ESS score of 10 and met minimal PAP usage of 4 h a night for at least 70% of nights with a residual apnea-hypopnea index (AHI) ≤ 10. On MSLT, 31% of patients had an average sleep onset latency (SOL) 8 min, 35% had a SOL between 8 and 11 min, and 35% had SOL 11 min.After optimizing PAP therapy and sleep in patients with OSA and residual EDS, the majority were found to have objective findings of an abnormally short SOL on MSLT. This is further evidence that there is a distinct OSA phenotype that will have persistent EDS despite appropriate treatment of their sleep-disordered breathing. Objective testing to quantify the degree of sleepiness is recommended for OSA patients with residual EDS.

Historically, scientific knowledge gaps—including a lack of information regarding the minimum amount of sleep needed to sustain nominally adequate, militarily relevant performance, and nescience of the potential impact of chronic sleep restriction on health and psychological well-being—have hindered decision-making vis-a-vis sleep/alertness management in operational environments. However, against a backdrop of increasing awareness of the importance of sleep for sustaining both performance and health, military researchers are currently doing the following: (1) developing a comprehensive, individualized sleep/alertness management system to optimize the general effectiveness of military personnel (ie, without regard to the potential relationship between sleep and specific aspects of military performance, thus sidestepping what has historically been an impediment to development of such a system); and (2) investigating the prevalence, potentially unique etiology (eg, resulting from the interaction of long-term exposure to combat-related stressors and sleep restriction), and treatment of sleep disorders and comorbidities in the military population.

Introduction An estimated twenty-five percent of American women are at high risk of having obstructive sleep apnea (OSA). However, male sex is the predominantly reported risk factor. Women are less likely to report “classic” symptoms such as snoring that prompt referral for sleep evaluation. This dichotomy potentially represents a disparity in clinical evaluation and treatment of OSA in women. Consumer digital health devices are frequently used to monitor sleep in people with and without sleep disturbances. They are generally highly sensitive yet have lower specificity when compared with formal actigraphy or polysomnography. They may be used in conjunction with physician evaluation to guide decision-making. Report of Cases: A 33 year-old female with a pertinent past medical history of obesity (BMI 37.83 kg/m ), depression, chronic pain, and anxiety was referred to our sleep center with a multi-year history of excessive daytime fatigue and non-restorative sleep that persisted despite healthy habits counseling and unremarkable lab evaluation. She ultimately presented her primary care physician with biometric data collected by her Garmin watch and Oura ring. This data, which included a reported low SpO of 83%, motivated a referral to Sleep Medicine. Her presentation Epworth Sleepiness Scale (ESS) score and Insomnia Severity Index (ISI) were 14 and 17, respectively. Polysomnography revealed an AHI of 32.6/hr, oxygen nadir of 79%, ODI of 28.7/hr, and a 97.2% sleep efficiency. PLMS index was 23.2/hour but did not contribute to sleep fragmentation and there was increased proportion of stage N3 sleep (28.2%). Severe OSA was treated with APAP. The two month follow-up ESS and ISS improved to 9 and 4, respectively. Device data revealed greater than 6 hours of consistent nightly use with a residual AHI of 3.1/hr. She subjectively stated APAP “has been a life changer” personally and professionally, as well as spousal report of resolution of snoring. Her consumer devices similarly reported improved sleep measures. Conclusion Minorities and women may be underserved in evaluation, diagnosis, and treatment of OSA. Portable monitoring using readily available consumer biometric devices may be a viable strategy for patients to further identify high risk features and prompt referral by primary care. Support (If Any) This work was supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health (DM170708; Mysliwiec) and the Air Force Research Laboratory, Wright Patterson Air Force Base, Ohio (FA8650-18-2-6953; Peterson).

Introduction According to the American Academy of Sleep Medicine (AASM) guidelines, split-night polysomnography (SN-PSG) is an acceptable alternative to full-night PSG (FN-PSG) and may be considered in patients with an apnea-hypopnea index (AHI) ≥20/hr within the first 2 hours of the study. While SN-PSGs are an accurate approximation of moderate-to-severe obstructive sleep apnea (OSA), there remains the potential to misclassify the severity of sleep disordered breathing. Risks associated with the misclassification of OSA severity may be significant in high-risk professions such as active duty service members (ADSMs). The purpose of our study was to determine the accuracy of split-night polysomnography (SN-PSG) in a cohort of ADSMs. Materials and methods We conducted a retrospective review of ADSMs undergoing FN-PSG with approval by our institution's Department of Clinical Investigation. FN-PSG data were processed using t-test, ANOVA, Chi-Squared, and logistical regression using JMP v12.0 to obtain partial-night data for the first 2 and 3 hours of recording. Significance was established with p-value less than 0.05. OSA severity was determined by calculating the AHI of each subject's FN-PSG and SN-PSG. Results Three-hundred patients were included in the study. Overall 79% were male with a mean age of 37.6 ± 8.4 years and mean BMI of 28.5 ± 3.3 kg/m2. Of our cohort, 112 patients (37%) would have qualified for a SN-PSG, of which 94 (84%) were appropriately classified and 18 patients (16%) were misclassified. Conclusions In the relatively young, non-obese ADSM population, the majority did not qualify for a SN-PSG. The 3-hour SN-PSG accurately determined OSA severity in those with moderate-severe OSA; however, some patients with mild OSA would have been misclassified which can result in unnecessary duty limitations. A SN-PSG may not be ideal for this population.

INTRODUCTION: We evaluated whether insomnia symptom severity was associated with cognitive function, and whether this relationship was modified by biomarkers associated with Alzheimer’s disease risk. METHODS: We examined insomnia symptoms and neuropsychological performance 3.4 years later in 511 dementia-free Framingham Heart Study participants (62.65 ± 8.7 years, 50.9% male). Additionally, we explored insomnia symptoms combined with self-reported short habitual sleep duration and effect modification by apolipoprotein E (APOE) ε4 allele status. RESULTS: More severe insomnia symptoms were associated with lower performance on global cognition, and immediate and delayed Logical Memory recall, especially when insomnia symptoms were combined with short sleep duration. The association between insomnia symptoms and poorer memory recall was more pronounced in APOE ε4 allele carriers. DISCUSSION: Insomnia symptom severity was associated with worse subsequent global cognitive and memory performance, which was especially apparent in APOE ε4 allele carriers, suggesting that poor sleep might be particularly detrimental when the brain is already vulnerable to neurodegeneration.

Risks 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.

STUDY OBJECTIVES: Military personnel frequently experience sleep difficulties, but little is known regarding which military or life events most impact their sleep. The Military Service Sleep Assessment (MSSA) was developed to assess the impact of initial military training, first duty assignment, permanent change of station, deployments, redeployments, and stressful life events on sleep. This study presents an initial psychometric evaluation of the MSSA and descriptive data in a cohort of service members. METHODS: The MSSA was administered to 194 service members in a military sleep disorders clinic as part of a larger study. RESULTS: Average sleep quality on the MSSA was 2.14 (on a Likert scale, with 1 indicating low and 5 indicating high sleep quality), and 72.7% (n = 140) of participants rated their sleep quality as low to low average. The events most reported to negatively impact sleep were stressful life events (41.8%), followed by deployments (40.6%). Military leadership position (24.7%) and birth/adoption of a child (9.7%) were the most frequently reported stressful life events to negatively impact sleep. There were no significant differences in current sleep quality among service members with a history of deployment compared with service members who had not deployed. CONCLUSIONS: The MSSA is the first military-specific sleep questionnaire. This instrument provides insights into the events during a service member’s career, beyond deployments, which precipitate and perpetuate sleep disturbances and likely chronic sleep disorders. Further evaluation of the MSSA in nontreatment-seeking military populations and veterans is required. CITATION: Mysliwiec V, Pruiksma KE, Brock MS, et al. The Military Service Sleep Assessment: an instrument to assess factors precipitating sleep disturbances in U.S. military personnel. J Clin Sleep Med. 2021;17(7):1401–1409.

Background Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. Methods This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™’s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM’s sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM’s sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. Discussion Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. Trial registration ClinicalTrials.gov NCT04366284. Registered on 28 April 2020.

Study Objectives Epidemiologic studies of obstructive sleep apnea (OSA) and insomnia in the U.S. military are limited. The primary aim of this study was to report and compare OSA and insomnia diagnoses in active duty the United States military service members. Method Data and service branch densities used to derive the expected rates of diagnoses on insomnia and OSA were drawn from the Defense Medical Epidemiology Database. Single sample chi-square goodness of fit tests and independent samples t-tests were conducted to address the aims of the study. Results Between 2005 and 2019, incidence rates of OSA and insomnia increased from 11 to 333 and 6 to 272 (per 10,000), respectively. Service members in the Air Force, Navy, and Marines were diagnosed with insomnia and OSA below expected rates, while those in the Army had higher than expected rates (p < .001). Female service members were underdiagnosed in both disorders (p < .001). Comparison of diagnoses following the transition from ICD 9 to 10 codes revealed significant differences in the amounts of OSA diagnoses only (p < .05). Conclusion Since 2005, incidence rates of OSA and insomnia have markedly increased across all branches of the U.S. military. Despite similar requirements for overall physical and mental health and resilience, service members in the Army had higher rates of insomnia and OSA. This unexpected finding may relate to inherent differences in the branches of the military or the role of the Army in combat operations. Future studies utilizing military-specific data and directed interventions are required to reverse this negative trend.

While forehead cooling has been studied in patients with insomnia in the absence of comorbid medical/psychiatric disorders, it has never been evaluated in patients with insomnia in the presence of co-morbid medical/psychiatric disorders.Veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions received 4-week open-label, in-home, nightly treatment with a forehead cooling device (14-16 °C) along with personalized sleep hygiene following baseline assessments. Pre- and post-treatment, participants completed the Insomnia Severity Index (ISI), the Generalized Anxiety Disorder 7-item scale (GAD-7), and the Patient Health Questionnaire 9-item scale (PHQ-9). Participants recorded daily sleep and anxiety/arousal symptoms.Of 24 veterans (20 men, 42.2 ± 9.5 years), 17 (71%) had marked insomnia severity improvement (a decrease of8 on the ISI) and 10 (42%) participants scored 7 or below on the ISI at post-treatment reflecting remission. Participants reported reductions in sleep onset latency (SOL) (F = 12.9, p0.001), and wakefulness after sleep onset (WASO) (F = 8.4, p0.001) across treatment. They also had significant reductions in insomnia severity (t = 10.04, p0.001), anxiety (t = 3.59, p = 0.002), and depression (t = 7.75, p0.001) from pre- to post-treatment.This pilot study shows that 4-week nightly use of a forehead cooling device produces improvements in insomnia, anxiety, and depressive symptoms in veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions. Controlled studies are warranted to determine the role of this therapy in the management of insomnia in veterans.Not required as a small sample size feasibility study.

Sleep disturbances, posttraumatic stress disorder, and traumatic brain injury are highly prevalent in military personnel and veterans. These disorders can negatively impact military performance. Although literature evaluating how posttraumatic stress disorder and traumatic brain injury directly impact military performance is limited, there is evidence supporting that these disorders negatively impact cognitive and social functioning. What is not clear is if impaired performance results from these entities individually, or a combination of each. Further research using standardized evaluations for the clinical disorders and metrics of military performance is required to assess the overall performance decrements related to these disorders.

The article of record as published may be found at https://doi.org/10.1093/oso/9780190455132.003.0010 This chapter explores the influence of sleep on human performance and well-being. A general discussion of the role of sleep in humans is followed by a description of the functions of various stages of sleep. The authors explore causal factors of insufficient sleep and inventory known effects of sleep restriction on human performance. They then describe the particular challenges of fatigue and sleep deprivation in military operational environments. The efficacy of fatigue countermeasures and alertness aids commonly used in military settings is presented. The chapter concludes with an argument for more deliberately protecting and promoting sleep, particularly in vulnerable populations such as shiftworkers.

IntroductionIn the United States (U.S.), approximately 35% of adults sleep less than 7 hours per night. The relationship between social media use and insufficient sleep has not thoroughly been examined among adults. The purpose of this study was to determine if social media use is associated with insufficient sleep among a sample of U.S. Army Soldiers.MethodsThis study surveyed 9,052 U.S. Soldiers in 2018 via a self-administered online questionnaire. Using multivariable logistic regression, we examined the association between social media use (ResultsOverall, 54.9% of Soldiers reported insufficient sleep. There was no significant relationship between excessive social media use and insufficient sleep in the multivariable logistic regression (OR: 1.03; CI: 0.87–1.23). The covariates of sex, race/ethnicity, rank, hazardous alcohol consumption, anxiety, and depression were significantly associated with insufficient sleep. Soldiers who reported symptoms of anxiety were more than twice as likely (OR: 2.11; CI: 1.65–2.70) to report insufficient sleep than Soldiers without signs of anxiety. Additionally, Soldiers who reported depressive symptoms were 85% (OR: 1.85; CI: 1.44–2.37) more likely to experience insufficient sleep than Soldiers without signs of depression.ConclusionSufficient sleep is essential to ensuring mission readiness and preventing accidental morbidity and mortality among Soldiers. The findings of this analysis do not suggest a link between extended social media use and insufficient sleep. However, though previously uninvestigated, Soldiers reporting symptoms of anxiety and depression were more likely to experience insufficient sleep compared to unafflicted Soldiers. Therefore developing a culture that encourages Soldiers to seek necessary behavioral health screening and care could be a key primary strategy to promote adequate sleep.

Comorbid insomnia and sleep apnea (COMISA) is prevalent and carries significant morbidity but lacks a standardized diagnostic and therapeutic approach. Through a critical evaluation of the literature, we propose a novel approach to COMISA that incorporates the underlying etiology and existence of different phenotypes in this disorder. A low arousal threshold and/or hyperarousability may underlie the development of COMISA. Pretreatment symptoms may serve as baseline predictors of response to positive airway pressure therapy in COMISA and differentiate insomnia secondary to OSA from independent insomnia. A variety of therapeutic strategies for COMISA have been put forward with evidence supporting the use of monotherapy or combined therapy in the appropriate clinical setting. Patients with either OSA or insomnia must be effectively screened for both disorders based on presenting symptoms and response to therapy. Recognition of the underlying etiology of COMISA and the different COMISA phenotypes can guide therapy.

Sleep disturbances are endemic in military personnel with nonclinical populations averaging 6 hours of sleep. The Pittsburgh Sleep Quality Index (PSQI), however, has not been validated in this popu...

Hospital readmissions are an important metric of quality and safety. This study seeks to characterize the relationship between readmissions and obstructive sleep apnea (OSA). A better understanding of this relationship could be utilized to develop preventative measures and reduce readmission rates.A retrospective review of patients discharged over a 24-month period to a Department of Defense hospital was conducted. Medical records review provided demographic data, presence of OSA and comorbid diseases, and whether readmission occurred within 30 days of discharge. Statistical analysis assessed risk factors for readmission, and multivariate analysis was performed. Next, 125 readmitted patients with OSA were randomly selected for detailed chart review and compared to a matched cohort that was not readmitted.Of 22,261 unique patients discharged, 1,899 (8.5%) were readmitted. Patients with OSA had a readmission rate of 11.4% versus 7.6% for patients without OSA (This study found OSA to be an independent risk factor for readmission within 30 days of discharge. PAP therapy appears to be underutilized in patients with known OSA. Additional studies are needed to define the relationship between OSA, PAP adherence, and hospital readmission.

Military personnel experience posttraumatic stress disorder (PTSD), which is associated with differential DNA methylation across the whole genome. However, the relationship between these DNA methylation patterns and clinically relevant increases in PTSD severity is not yet clearly understood. The purpose of this study was to identify differences in DNA methylation associated with PTSD symptoms and investigate DNA methylation changes related to increases in the severity of PTSD in military personnel. In this pilot study, a cross-sectional comparison was made between military personnel with PTSD (n = 8) and combat-matched controls without PTSD (n = 6). Symptom measures were obtained, and genome-wide DNA methylation was measured using methylated DNA immunoprecipitation (MeDIP-seq) from whole blood samples at baseline and 3 months later. A longitudinal comparison measured DNA methylation changes in military personnel with clinically relevant increases in PTSD symptoms between time points (PTSD onset) and compared methylation patterns to controls with no clinical changes in PTSD. In military personnel with elevated PTSD symptoms 3 months following baseline, 119 genes exhibited reduced methylation and 8 genes exhibited increased methylation. Genes with reduced methylation in the PTSD-onset group relate to the canonical pathways of netrin signaling, Wnt/Ca+ pathway, and axonal guidance signaling. These gene pathways relate to neurological disorders, and the current findings suggest that these epigenetic changes potentially relate to PTSD symptomology. This study provides some novel insights into the role of epigenetic changes in PTSD symptoms and the progression of PTSD symptoms in military personnel.

The article of record as published may be found at http://dx.doi.org/10.1093/milmed/usx116 Sleep 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.

Idiopathic rapid eye movement sleep behavior disorder is characterized by vocalizations and complex motor behaviors during sleep. We report a case of a 44-year-old male with a 20-year history of dream enactment behavior that was incidentally captured on a polysomnogram during an evaluation for obstructive sleep apnea. Genetic testing found the patient had a homozygous deletion for one of the five tandem repeats in exon 18 of the PER3 gene. This case highlights a potential genetic basis for idiopathic rapid eye movement sleep behavior disorder. CITATION: Brock MS, Shirley S, Rohena L, Moore BA, Mysliwiec V. Unexpected finding of idiopathic REM sleep behavior disorder in a young healthy male with snoring: a case report. J Clin Sleep Med. 2019;15(9):1369–1371.