Wednesday, June 26, 2013

CPAP Improves Migraine Burden in Patients With Sleep Apnea

BARCELONA, Spain — For migraine sufferers with obstructive sleep apnea (OSA), continuous positive airway pressure (CPAP) treatment can decrease the frequency of migraine attacks, their duration, and intensity. In addition, medication use and lost days from work were reduced, a study shows.

Presenting results here at the 23rd Meeting of the European Neurological Society (ENS), Hildegard Hidalgo, MD, from the Department of Neurology at Kamillus-Klinik in Asbach, Germany, said that 25% of patients with OSA also have migraines and that the frequency of OSA in patients with migraine is similar to that in the general population: about 12% in migraine without aura and about 7% in migraine with aura.

Migraine may be triggered by several factors, including foods, hormonal status, drugs, psychological state, sleep deficit or excess, sensory input, and environmental conditions, including altitude and hypoxia. In this prospective study, the researchers investigated the possible role of hypoxia during sleep and the long-term effects of CPAP therapy on migraine.

They screened 314 potential participants with OSA. Inclusion criteria were an apnea-hypopnea index (AHI) greater than 15 or greater than 5 with clinical symptoms (excessive daytime sleepiness, nonrefreshing sleep, sleep fragmentation, nocturia, decreased concentration, memory loss, or morning headaches), and a diagnosis of migraine according to International Classification of Headache Disorders, second edition, criteria. Additional inclusion criteria were being free of migraine prophylactic medications, oxygen therapy, or other central nervous system medications, and not having any other neurologic or psychiatric disorders. In-hospital video polysomnography was performed.

Of the 314 potential participants, 41 (13.1%) were included in the study, with an average age of 48.9 years and mean body mass index 30 ± 6.1 kg/m2 (20 women). They had a mean Epworth Sleepiness Scale score of 9.8 ± 4.8 and a mean AHI of 27.4 ± 25.4 episodes/hour at baseline. Twenty-one had migraine with aura, 19 had migraine without aura, and 1 had chronic migraine.

Thirty patients (73.2%) accepted CPAP therapy, with data on 24 at 1 year and on 18 at 2 years. Two patients dropped out because they did not accept CPAP long term, 3 were nonadherent (CPAP use <90%), and 7 were not accessible.

Improved Sleep Measures and Migraine Burden
Compared with baseline, polysomnography showed significant improvements at 1 year in AHI, mean duration of sleep-related breathing disorders, oxygen desaturation index (all P < .001), arousal index (P < .002), slow wave sleep (P = .031), and other measures. CPAP therapy significantly reduced migraine measures and disease burden.

Table. Migraine Measures and Disease Burden With CPAP
 
Migraine Measures At Diagnosis (n = 41) 1 Year (n = 24) 2 Years (n = 18)
Frequency of attacks (d/wk) 1.2 0.2 0.1
Attack duration (h) 22 3 3
Intensity 2.7 0.8 0.3
Burden of disease      
Medication intake (units/wk) 2.2 0.3 <0.1
Inability to work (d/mo) 1.2 0.3 0.3
Lost free days (d/mo) 2.1 0.4 0

Dr. Hidalgo concluded that CPAP is an effective therapy for both OSA and migraine in patients with both conditions. It improved nocturnal oxygen saturation, stabilized sleep, and increased slow wave sleep as a proportion of total sleep time. It also reduced the burden of migraine, so she recommended that symptoms of OSA should be considered in migraineurs.

A Single Treatment
Session moderator Pierre Maquet, MD, PhD, professor of neurology at the University of Li├Ęge in Belgium, who was not involved in the study, commented to Medscape Medical News that the study is interesting, especially because at least migraine with aura is recognized as a risk factor for stroke, as is apnea, "so it's nice to see that there is some way to treat both with a single treatment."

However, he pointed out that the study suffers from a lack of a control population, such as participants possibly receiving low-pressure CPAP as a sham treatment or periods of the night in which the CPAP is turned off. "So they can't assess which is the proportion of the effect which is due to the treatment and what's the proportion that is just due to placebo effect, he said.

He noted that the mere fact of having contact with patients over 2 years might explain part of the effect. "The more you see patients, the better they get," he said. A better experiment, he explained, may be a randomized, placebo-controlled, crossover study.

Nonetheless, Dr. Maquet said it makes sense that CPAP could aid migraines. Although no one knows the causes of migraines, they may involve a failure of energy metabolism in the neurons, so hypoxia could induce disruption of metabolism.

The study was not commercially funded. Dr. Hidalgo and Dr. Maquet have disclosed no relevant financial relationships.
23rd Meeting of the European Neurological Society (ENS). Abstract O314. Presented June 10, 2013.

Tuesday, June 25, 2013

VA looks to tighten sleep apnea rating schedule

The Department of Veterans Affairs is studying changes to disability ratings for obstructive sleep
apnea, particularly the 50-percent rating being awarded when VA physicians prescribe use of a CPAP, or continuous positive airway pressure machine, for sleep-deprived veterans.

“That’s definitely going to be the one they look at,” said Jonathan Hughes, a policy consultant for VA’s compensation service. “Because essentially there’s no functional impairment related to that” 50-percent rating for obstructive sleep apnea under the Veterans Affairs Schedule for Rating Disabilities (VASRD).

The good news for more than 114,000 veterans already drawing compensation for sleep apnea is their ratings would not be reduced with broad change to the rating schedule, Hughes explained. Current law prohibits that. Indeed, claimants still awaiting favorable decisions might not be impacted either because VASRD changes don’t happen quickly.

The only date Hughes could quote with certainty is that an ongoing effort to modernize the entire VASRD is to be completed by January 2016.

When interviewed Tuesday at VA headquarters in Washington D.C., Hughes had just delivered a briefing on sleep apnea at a public hearing of VA Advisory Committee on Disability Compensation. The panel, established in 2010, counsels the VA secretary on maintaining or readjusting the VASRD.
This day members wanted to know about sleep apnea including how the condition is rated in its various forms, how service-connection is established for a disorder largely associated with obesity, and what factors are behind the recent explosion of claims, as reported here in late May.

Mike Webster, a family law attorney in Florida, complained to the House Veterans Affairs Committee of widespread abuse of VA claims for sleep apnea. Since then, Webster has heard from staff on the veterans affairs oversight subcommittee that a “team” is looking into his allegations.

“Sleep apnea definitely has become more of an issue over the past several years,” Hughes said as he began his briefing. He gave some of the same data on sleep apnea cases published here, including that VA had rated 983 veterans for sleep apnea in 2001 and almost 25,000 last year. He added that 13 percent of roughly 427,000 veterans who served after 9/11, and draw VA disability compensation today, have service-connected sleep apnea.

“Thirteen percent? That’s staggering,” said committee member Dr. Michael Simberkoff, chief of staff of the VA New York Harbor Health System and a professor at New York University School of Medicine.

The advisory committee chairman, retired Army Lt. Gen. James Terry Scott, also chaired the 2007 Veterans’ Disability Benefits Commission. Scott asked colleagues to back his recommendation that VA Secretary Eric Shinseki commission the Institute of Medicine, part of the National Academies of Science, to conduct a study of sleep apnea in the veteran population.

“Short of a scientific study by a well-recognized and competent authority, I think we’re still working with rumor and innuendo,” Scott said after the briefing, which he said was “extremely informative and…put to rest a lot of different theories and conventional wisdoms.”

One issue addressed was conventional wisdom by some sleep disorder experts that sleep apnea is related to post-traumatic stress disorder.

“We haven’t seen any medical correlation between sleep apnea and PTSD,” Hughes said.  Still the most common path to a sleep apnea rating “is people who are overweight ... getting diagnosed” as they separate or retire.

“Why would they have sleep apnea during service,” asked the committee’s Deneise Turner-Lott, an administrative judge with the Mississippi Workers’ Compensation Commission. “I mean they are not overweight.”

Weight remains the most common cause of sleep apnea, Hughes said, even when diagnosed in service.

Another committee member asked Hughes to explain the link between sleep apnea and military service.

“I don’t think there is any medical link to service,” he said. “There is not something we can point to in service that actually causes sleep apnea.”

Hughes speculated that the rise in claims is related to heighten awareness of the condition among service members and veterans.

Committee member Mark W. Smith wanted to know why VA grants 50 percent disability compensation to vets who need a CPAP for a good night’s sleep. Hughes explained that the rating was set years ago based on studies that estimated “average impairment in earnings loss.”
Simberkoff noted that need for a CPAP means “continuous use of an external agent to maintain their health.”

But Smith followed up by comparing a CPAP to eyeglasses.

“If I don’t use my glasses, my earnings are going to be a hell of a lot less because I’m blind,” he said. “Once I put them on, no problem.” If CPAP “pretty much cures the problem, why would you give a service rating for it?”

Indeed, until VA and the Department of Defense integrated disability evaluation systems for members being medically retired, 99 percent of service members diagnosed with sleep apnea only got a zero percent rating from their branch of service, Hughes said.

But armed with an in-service diagnosis, separated members with sleep apnea can file claims with VA, and 88 percent are rated 50 percent disabled. That a rating level is assured once a CPAP is prescribed to keep the air passage clear during sleep, preventing interruptions in breathing or apneas, which lead to daytime drowsiness and cognitive impairment.

Hughes said a CPAP is not effective for treating persons with the less common “central” sleep apnea, which usually is caused by cardiac failure or neurologic disease and treated with drugs.

Hughes indicated VA benefit and health experts already were at work on reforming VASRD for respiratory illnesses including sleep apnea.

Hughes later said the jump to 50 percent when a CPAP is prescribed has no tie to functional impairment, and therefore “if anything is revised it would be that one. I don’t know if the other [percentages] will stay the same ... but that’s the significant part of the inquiry, the 50 percent.”

To comment, write Military Update, P.O. Box 231111, Centreville, VA, or email milupdate@aol.com or twitter: Tom Philpott @Military_Update

Monday, June 17, 2013

Sleep Apnea? Stick With Your CPAP

Obstructive sleep apnea is the most common type of apnea – which itself means “without breath.” In sleep apnea there are frequent cessations of breathing that last 10 seconds or more. One of the most successful treatments for obstructive sleep apnea is something known as CPAP, which stands for Continuous Positive Airway Pressure. A machine pushes air through the airway at a pressure high enough to keep the airway open during sleep. The problem is that the patient has to wear a mask of some sort, to deliver the air. There are many different masks, including nasal pillows, nasal masks, and full-face masks. But many patients find that any mask is troublesome to wear – and therefore it’s hard to follow the doctor’s advice to use CPAP.

A study from Brazil, has reported findings showing that CPAP is worthwhile. Over 400 men with, on average, more than 30 apnea episodes an hour, were allocated to CPAP or no treatment for 4 months. During this time the thickness of the cell layers lining the arteries decreased significantly. This indicates clearly an improvement in atherosclerosis, the degenerative artery disease that precedes heart attack, stroke, and peripheral arterial disease. Until now, atherosclerosis has not been proven a complication of sleep apnea. This may change.

Anyway, these new findings should make any obstructive sleep apnea sufferer think twice before abandoning his CPAP apparatus.

Thursday, June 6, 2013

Sleep Type Predicts Day and Night Batting Averages of Major League Baseball Players

It’s summer and baseball is one our favorite pastimes. Would you believe the sleep type of a major league baseball player actually predicts his day and night batting average? Sure enough, a study of 16 players from seven MLB teams (Houston Astros, Los Angeles Angels, Los Angeles Dodgers, Pittsburgh Pirates, St. Louis Cardinals, San Francisco Giants, and Toronto Blue Jays) indicate that “morning type” players—those who prefer to go to bed early and wake up early—had a higher batting average as compared to “evening type” players—those who prefer to stay up late and wake up late—in games that started before 2 pm. But, evening types had a higher batting average than morning types in games that started between 2 pm and 7:59 pm.

According to Dr. W. Christopher Winter, the principal investigator for the study and the medical Director of the Martha Jefferson Hospital Sleep Medicine Center in Charlottesville, Virginia, “Our data, though not statistically significant due to low subject numbers, clearly shows a trend toward morning type batters hitting progressively worse as the day becomes later, and the evening type batters showing the opposite trend.”

So, a player’s sleep preference could actually impact his batting average. Wow.

The results from this study could potentially create a new way to evaluate athletic talent. Could this spill over into other professional sports? Say basketball and football. What about tennis and golf?

Pretty interesting. To read the article recently published in Sleep Review magazine, click here.

Tuesday, June 4, 2013

SleepSeeker by ResMed gives patients access to their therapy data

ResMed is proud to introduce SleepSeeker, a new online therapy-management tool from Wake Up to Sleep. Wake Up to Sleep is an interactive patient support community for people with sleep apnea. The program provides free tools and resources for every stage of a person’s journey. Whether an individual is just beginning to learn about sleep apnea or has been living with it for many years, the sleep coaches, supportive community and website can help patients live well on sleep apnea therapy.
Download Brochure
What is SleepSeeker?
SleepSeeker is a free online tool that allows patients to upload therapy data from their S9™ device (via an SD card) so they can view their usage, events and mask leak.
How can patients sign up?
Patients can register at WakeUpToSleep.com and become part of the community. Once they’re a registered member, they can access SleepSeeker for free!

What are the benefits of this tool?
SleepSeeker provides an easy way for patients to stay engaged in their therapy by giving them visibility into their progress. It also gives them the option to create plans, set goals and even challenge other users in order to stay motivated.
SleepSeeker—along with other support resources on WakeUpToSleep.com—helps patients get through the critical first weeks of therapy after titration. It can help decrease the number of callbacks you receive and lead to improved compliance and better health outcomes.
Learn more about SleepSeeker today.
Sincerely,
Wake Up to Sleep Team
WakeUpToSleep.com