Abstract Introduction Epic dreaming, though not formally defined in major sleep medicine guidelines, is recognized in clinical practice as unusually vivid, mundane, and immersive dreaming that unfolds in prolonged, elaborate, narrative-rich sequences. Patients often report dreaming continuously throughout the night, frequently involving relentless or repetitive activity, such as endlessly walking, that leaves them feeling drained upon awakening. Clinically, epic dreaming is significant because it frequently accompanies fragmented, non-restorative sleep and marked daytime fatigue, even when objective sleep evaluations are unremarkable. Given its rarity and the absence of standardized criteria, formal treatment guidelines are lacking. Report of case(s) We present the case of a 47-year-old male with generalized anxiety disorder and asthma with a long-standing history of nightly epic dreaming, describing vivid, immersive dreams often centered on unsuccessful attempts to resolve a problem. These dreams lasted throughout the night, triggered two to three awakenings, and left him exhausted, struggling to resume sleep, and markedly fatigued during the day. He denied alcohol or recreational drug use. Notably, several relatives—including his brother, maternal cousin, and maternal aunt—reported similar dream patterns. A prior home sleep apnea test was unremarkable. Trials of anxiolytics and melatonin were ineffective, and prazosin provided only minimal benefit before being discontinued due to orthostatic dizziness. At the initial visit, cyproheptadine 4 mg nightly was started and a referral for CBT-I placed. The dose was gradually increased to 12 mg nightly. At one-month follow-up, he reported a meaningful reduction in dream frequency and intensity, improved sleep continuity with only one nighttime awakening, and less daytime fatigue. Although epic dreaming persisted, it was largely confined to the latter part of the night and was considerably less draining than before. Conclusion Epic dreaming presents as vividly immersive, narrative-rich dreaming that can lead to significant sleep disruption and daytime fatigue. Sustained dreaming has been reported to occur in both REM and non-REM sleep. This case demonstrates that cyproheptadine may provide meaningful symptomatic improvement, potentially through its known effects on suppressing REM and enhancing slow-wave sleep. The occurrence of similar dreaming patterns in multiple relatives raises the possibility of a familial predisposition and underscores the need for further research. Support (if any)

BACKGROUND:Over the past few years there have been major changes impacting the Sleep Fellowship application process. These changes included a shift to virtual interviews for the 2020 interview season and alignment of the sleep fellowship match date with the American Medical Board Specialties match date for the 2021 interview season. OBJECTIVE:Our study evaluates their effects on applicant numbers and feeder specialties as well as program directors' perspectives on outcomes of these changes. METHODS:A survey was sent to all program directors of ACGME-accredited Sleep Fellowship programs in April 2022. In addition, a request for aggregate deidentified sleep applicant rank list and match data was submitted for the sleep match for academic years from 2012 to 2024. RESULTS:For the 2020 and 2021 interview seasons, program directors agreed that they received more applicants than the years before though they did not feel that this affected their match results or overall recruitment. Most program directors were in favor of these changes. The NRMP data supported these trends. The ratio of applicants to position increased over 1.0 for the first time in 2021 and has remained over 1.0 since then. However, the increase in applicants in 2022 and 2023 were entirely driven by those who ranked sleep as their non-preferred specialty. CONCLUSION:The advent of virtual interviews has allowed applicants to apply to more programs. The alignment of the sleep fellowship match further increased the number of applicants. However, the increase appears partially related to more applicants ranking sleep medicine as their non-preferred specialty.

Non-REM (NREM) parasomnias comprise abnormal sleep-related behaviors, autonomic nervous system function, and emotional experiences that typically arise out of deep NREM sleep. Categorized broadly as disorders of arousal (DoA), confusional arousals (CoA), sleepwalking (SW), and sleep terrors (ST) share common pathophysiological mechanisms and contributing factors. Sexsomnia is classified as a variant of CoA and SW, while sleep-related eating disorder is classified as a separate NREM parasomnia. These parasomnias emerge due to incomplete dissociation of wakefulness from NREM sleep, resulting in partial arousal characterized by decreased consciousness during motor and emotional manifestations. The behaviors emerge as a result of the interplay of various predisposing and priming factors with the additional layer of precipitating conditions. Cyclic alternating patterns and abnormal slow wave synchronization increase susceptibility to developing these behaviors in the background of genetic predisposition. We will discuss current diagnostic criteria, differential diagnoses, implications, and management of these parasomnias. Recent scientific developments in this area will be discussed, especially in reference to etiopathogenesis and treatment strategies of lesser-studied subtypes such as sexsomnia. The mainstay of treatment comprises alleviating the contributing factors and treating any comorbid sleep disorders that may curtail sleep duration and also increase abnormal arousal. Behavioral interventions can be beneficial, although sometimes less established pharmacotherapy is also utilized.

Abstract Introduction N24SWD is a circadian rhythm sleep disorder (CRSD) in which there is misalignment between the 24-hour light dark cycle and the non-entrained endogenous circadian rhythm of sleep wake propensity. We present case of a sighted individual, incidentally noted to have FN24SWD upon review of his PAP download data. Report of case(s) A 75-year-old sighted, single male with major depressive disorder (MDD), generalized anxiety disorder (GAD), obstructive sleep apnea (OSA), restless leg syndrome (RLS), insomnia and hypertension presented to sleep clinic. Patient after retirement spent most of his time working on small engineering projects and programming. He reported regular use of PAP with average daily use of 7 hours and 11 minutes. PAP data review revealed well controlled OSA with residual apnea-hypopnea index of 3.1/ hour. His time in bed delayed approximately 1 to 2 hours each night and would cycle around every 20 days with 1 to 2 days in a month without any sleep. His Epworth Sleepiness Scale score was 3/24. Medications included gabapentin and ropinirole for RLS, trazodone, melatonin for insomnia, buspirone, citalopram. Based on the patient’s history, corroborated by PAP device data, diagnosis of behaviorally induced Non24SWD was made. Patient reported intermittent insomnia managed by above stated medications and thus reported no impact on his social life. Thus, he deferred treatment to entrain the rhythm. Conclusion Treatment for CSRDs comprises of melatonin in sighted individuals and melatonin receptor agonists in blind. In our patient, melatonin was used ad lib as a sleep promoting agent. Lack of regular daytime bright light exposure and light exposure from screens at night contributed to lack of entrainment . It is usually noted in blind individuals due to lack of photic input to circadian pacemaker. In sighted individuals, delayed sleep phase, decrease light exposure, psychiatric disorders, TBI or dementia is noted. In our case anxiety and depression were noted. This case highlights the unexpected discovery of Non 24SWD on detailed review of PAP download data in case of good PAP adherence, essentially replacing actigraphy. Thus, in CPAP compliant patient, detailed PAP review can help identify circadian disorders especially where actigraphy may be difficult to obtain. Support (if any)

Sleep terrors, categorized under disorders of arousal, more prevalent in pediatric population, generally are self-limited but sometimes can persist or occur in adulthood. These are primed by factors enhancing homeostatic drive on backdrop of developmental predisposition and are precipitated by factors increasing sleep fragmentation resulting in dissociated state of sleep with some cerebral regions showing abnormal slow wave activity and others fast activity. This phenotypically evolves into abrupt partial arousal with individual arousing from N3 or N2 sleep with behaviors representing intense fear such as crying with autonomic hyperactivity. There is no recollection of the event, and lack of vivid dream mentation although fragmented imagery may be noted. Behavioral management is of prime importance including addressing precipitating factors, family reassurance, safety measures, and scheduled awakenings. Pharmacologic agents such as clonazepam and antidepressants are used infrequently in case of disruptive episodes.

BACKGROUND: Traumatic brain injury (TBI) is a hallmark of wartime injury and is related to numerous sleep wake disorders (SWD), which persist long term in veterans. Current knowledge gaps in pathophysiology have hindered advances in diagnosis and treatment. OBJECTIVE: We reviewed TBI SWD pathophysiology, comorbidities, diagnosis and treatment that have emerged over the past two decades. METHODS: We conducted a literature review of English language publications evaluating sleep disorders (obstructive sleep apnea, insomnia, hypersomnia, parasomnias, restless legs syndrome and periodic limb movement disorder) and TBI published since 2000. We excluded studies that were not specifically evaluating TBI populations. RESULTS: Highlighted areas of interest and knowledge gaps were identified in TBI pathophysiology and mechanisms of sleep disruption, a comparison of TBI SWD and post-traumatic stress disorder SWD. The role of TBI and glymphatic biomarkers and management strategies for TBI SWD will also be discussed. CONCLUSION: Our understanding of the pathophysiologic underpinnings of TBI and sleep health, particularly at the basic science level, is limited. Developing an understanding of biomarkers, neuroimaging, and mixed-methods research in comorbid TBI SWD holds the greatest promise to advance our ability to diagnose and monitor response to therapy in this vulnerable population.

Abstract Introduction Chronic advanced respiratory assist device (RAD) management for complex sleep related breathing disorders is an overlooked area in sleep and pulmonary medicine education. Robust educational curriculum on practical management of advanced PAP therapies in sleep medicine fellowship programs is lacking. This void led our team to design innovative practical hands-on skills workshop to help facilitate learning. Methods Sleep faculty with area of expertise in education, sleep, medicine, and pulmonary fields designed a practical skills workshop titled “NIV skills workshop” consisting of introductory briefing, 3 clinical vignettes and post session debriefing. Cases were developed to highlight strategies on empiric use, PAP mode selection, setting adjustment and troubleshooting for complicated sleep related breathing disorders including neuromuscular disorders and hypoventilation to improve knowledge and comfort with prescription and management of the devices. RPSGTs helped with conduction of workshop with 3 stations, each dedicated to a clinical case with devices available to practice adjustments based on clinical scenarios. The learners rotated through these stations with a faculty moderating each case. Pre and post session surveys were conducted to assess workshop effectiveness in improving participants' level of comfort in modality selection, empiric settings, adjustment, and troubleshooting. Participants responded with numerical values based on Likert scale. A paired t-test was conducted to assess pre and post workshop skills gain. The workshop was conducted for 2 consecutive sleep fellowship batches and thus survey results were obtained from all the leaners(n=6) Results Improvement in mean scores was noted in level of confidence in PAP modality selection (3.3 vs. 4, p= 0.05), empiric device settings (2.3 vs. 3.7, p=0.0007), complex PAP therapy adjustment (2.6 vs. 3.7, p=0.006) and dyssynchrony troubleshooting (2 vs. 3.8, p=0.0009). High mean scores of 4.5 and 4.8 (scale of 0-5) were noted for confidence in RAD management skills and impact on clinical practice from workshop. Conclusion In addition to conventional didactic teaching on advanced PAP management, a practical hands-on workshop is a highly effective tool to improve trainees’ knowledge and confidence in chronic advanced device management and should be incorporated as integral part of curriculum. Such workshops should be extended to learners across the spectrum of training. Support (if any)

Abstract Introduction Obstructive sleep apnea can cause fragmented sleep which decreases total sleep time thus decreasing sleep efficiency. Studies have shown improvement in sleep efficiency with the treatment and adherence to therapy for sleep apnea. Due to the CPAP shortage, alternative treatment options for sleep apnea have opted including Transoral awake state neuromuscular stimulation is a novel FDA-approved therapy for mild sleep apnea. Methods Transoral awake state neuromuscular stimulation device procured through the regulatory process at VA Minneapolis is offered to veterans with Mild OSA (AHI 5-15) on a home sleep study. A retrospective data analysis was done on the sleep efficiency of veterans who completed the initial 6 weeks of at least 20 minutes of daily followed by maintenance of 2 weeks of twice weekly use. Sleep efficiency was calculated by total sleep time divided by total recording time multiplied by 100. Results A total of 112 patients with mild OSA were offered devices as an alternative option for treatment during the period of December 2021 to August 2022. Of these, 22 veterans completed a post-therapy home sleep study. The average age of patients is 53.22 years (ranging from 27-75). The average mean sleep efficiency Pre-therapy was 78.86% (ranging from 62.55% - 95.29%) post-therapy was 82.97% (ranging from 63.52% - 92.23%) A paired t-test was obtained for sleep efficiency which showed a mean difference of 4.11% with a p-value of 0.150 which is statistically non-significant. Conclusion Sleep efficiency can be affected by multiple co-morbid conditions among veterans though our study did show a mean difference of 4.11% pre- and post-therapy it was not statistically significant with a p-value of 0.150 that could be related to the small sample size. We proposed that to evaluate sleep efficiency a large sample size is needed with no other co-morbid conditions which can affect sleep efficiency. Support (if any)

Recent studies have begun to understand sleep not only as a whole-brain process but also as a complex local phenomenon controlled by specific neurotransmitters that act in different neural networks, which is called "local sleep". Moreover, the basic states of human consciousness-wakefulness, sleep onset (N1), light sleep (N2), deep sleep (N3), and rapid eye movement (REM) sleep-can concurrently appear, which may result in different sleep-related dissociative states. In this article, we classify these sleep-related dissociative states into physiological, pathological, and altered states of consciousness. Physiological states are daydreaming, lucid dreaming, and false awakenings. Pathological states include sleep paralysis, sleepwalking, and REM sleep behavior disorder. Altered states are hypnosis, anesthesia, and psychedelics. We review the neurophysiology and phenomenology of these sleep-related dissociative states of consciousness and update them with recent studies. We conclude that these sleep-related dissociative states have a significant basic and clinical impact since their study contributes to the understanding of consciousness and the proper treatment of neuropsychiatric diseases.

Free AccessLetters to the EditorApproaching year 3 of the Philips recall: what have we learned? Snigdhasmrithi Pusalavidyasagar, MD, John Poma, MBA, JD, Muna Irfan, MD, Robert Stansbury, MD, Conrad Iber, MD, Lynn Marie Trotti, MD Snigdhasmrithi Pusalavidyasagar, MD Address correspondence to: Snigdhasmrithi Pusalavidyasagar, MD, FAASM, Department of Medicine/PACCS Division, 420 Delaware Street SE, MMC 276, Minneapolis, MN 55455; Email: E-mail Address: [email protected] Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota Search for more papers by this author , John Poma, MBA, JD Patient Advocate, Massachusetts General Hospital, Boston, Massachusetts Search for more papers by this author , Muna Irfan, MD Department of Neurology, Veterans Affairs Medical Center, Minneapolis, Minnesota Search for more papers by this author , Robert Stansbury, MD Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia Search for more papers by this author , Conrad Iber, MD Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota Search for more papers by this author , Lynn Marie Trotti, MD Department of Neurology, Emory School of Medicine, Atlanta, Georgia Search for more papers by this author Published Online:August 1, 2023https://doi.org/10.5664/jcsm.10638SectionsEpubPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONWhile struggling to address the impact of the global coronavirus disease 2019 (COVID-19) pandemic on our patients, the sleep medicine community could hardly imagine the challenge ahead: an unprecedented medical device recall for the Philips Respironics positive airway pressure (PAP) devices and home ventilators. As we approach the recall’s third year, we are concerned about the questions that remain unanswered about its impact on our patients.Approximately 25 million devices were recalled, making it one of the largest medical device recalls.1 National organizations provided support when possible. The American Academy of Sleep Medicine issued an important statement and provided regular updates, including webinars, for the sleep community. The Journal of the American Medical Association regularly covered the recall, including examining the regulatory policy breakdown.1Leaders offered their guidance and experience. Morgenthaler et al2 shared a thoughtful patient-centered guide for rapid responses to medical device recalls outlining important components for sleep centers to consider in their own efforts. Owens et al3 authored a helpful statement on behalf of the American Thoracic Society identifying additional key steps for clinical teams. Tondo et al4 recently shared their experience switching patients with obstructive sleep apnea to different devices.All of these contributions helped the sleep medicine community find its way. However, despite sleep centers’ heroic efforts to provide care, we still know very little about the impact of the recall on patients globally. A coauthor to this Letter was a PAP user for more than 20 years at the time of recall—who faced impossible choices about their sleep, risks associated with continuing therapy or stopping, and ultimately, their quality of life.We must share our experiences. Recognizing that strategies implemented by a single sleep center may not be generalizable, due to differences in resources, patient populations, and access, we believe that publishing will be valuable in identifying lingering problems from the recall and potential solutions. In particular, it seems likely that the recall could have worsened existing inequities in sleep health, yet little has been published on the impact of the recall on health disparities. Our sleep medicine colleagues and patients in the global South are facing the same device safety issues but may be experiencing the recall effects in different ways.Therapy adherence is a lingering concern in sleep medicine, despite several advancements in technology. We believe that there is a high probability that PAP discontinuation increased during the recall for complex reasons, including device shortage, understandable concern, distrust of device safety, and, possibly, distrust of sleep medicine professionals who prescribed the PAP devices prior to the recall. We are unaware of any published data on our patients’ perspectives about these challenges or their evolving perspective on alternative treatment options due to the recall.Our hope is that the global sleep medicine community will begin to seek and share our patient experiences during the recall. We should also share our clinical experiences managing patient care during the recall, so we can better understand and debate the impact of this tremendous challenge and, importantly, be better prepared for the future.DISCLOSURE STATEMENTAll authors have seen and approved the manuscript. Mr. Poma serves on the Board of Trustees for LifeSpire of Virginia without compensation. Dr. Stansbury previously consulted with ResMed on design of new drugs or devices, clinical trials, the use of specific agents, or other research-related activities with honoraria. Dr. Trotti is a member of the Board of Directors of the American Academy of Sleep Medicine (AASM). Views expressed in this letter are those of the authors and do not necessarily reflect those of the AASM. The other authors report no conflicts of interest.REFERENCES1. Kadakia KT, Ross JS, Rathi VK. The Philips Respironics recall of ventilators and positive airway pressure machines—breakdowns in medical device surveillance. JAMA Intern Med. 2023;183(1):5–8. CrossrefGoogle Scholar2. Morgenthaler TI, Linginfelter EA, Gay PC, et al.. Rapid response to medical device recalls: an organized patient-centered team effort. J Clin Sleep Med. 2022;18(2):663–667. LinkGoogle Scholar3. Owens RL, Wilson KC, Gurubhagavatula I, Mehra R. Philips Respironics recall of positive airway pressure and noninvasive ventilation devices: a brief statement to inform response efforts and identify key steps forward. Am J Respir Crit Care Med. 2021;204(8):887–890. CrossrefGoogle Scholar4. Tondo P, Pronzato C, Risi I, et al.. Switch of nocturnal non-invasive positive pressure ventilation (NPPV) in obstructive sleep apnea (OSA). J Clin Med. 2022;11(11):3157. CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 19 • Issue 8 • August 1, 2023ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationMarch 26, 2023Submitted in final revised formApril 20, 2023Accepted for publicationApril 21, 2023Published onlineAugust 1, 2023 Information© 2023 American Academy of Sleep MedicinePDF download

Introduction Chronic nightmares are a common and disabling feature of posttraumatic stress disorder (PTSD) for which broadly effective treatments are still lacking. While imagery rehearsal therapy (IRT) demonstrates benefits for patients with idiopathic nightmares and some patients with PTSD-related nightmares, research indicates it may be less beneficial for veterans. Narrative therapy (NT) is a form of psychotherapy which is client-centered and value-focused and has demonstrated benefits for PTSD patients. The application of NT principles to IRT may provide a valuable therapeutic approach for treatment in veterans. Objective To perform a retrospective chart review of veteran clients participating in a novel, brief intervention developed by the first author consisting of IRT enhanced with NT principles (N-IRT) for the treatment of nightmares. The primary outcomes were nightmare frequency and intensity, and the secondary outcome was the impact of the intervention on nightmare distress and coping, subjective sleep quality, and overall PTSD symptoms. Materials and Methods We conducted retrospective chart reviews for eight veterans referred to the first author for the treatment of nightmares, who completed N-IRT, including baseline and end-of-treatment measures. The protocol involved a single 60-minute NT-enhanced rescripting session and assigned homework to rehearse the revised dream script, and a follow-up evaluation 4 weeks later. The subjects completed a sleep and nightmare interview developed by the first author and the PTSD Checklist at baseline and after the intervention at the follow-up evaluation. Paired t-tests were conducted to test for pre-to-post differences. Results In the statistical analysis, we observed a statistically significant and clinically meaningful reduction in the frequency (p = 0.04) and intensity of nightmares (p = 0.001) from pretreatment to the 1-month follow-up. Measures of nightmare-associated emotional distress, the ability to cope with nightmares, sleep duration and sleep efficiency, as well as overall PTSD symptoms also demonstrated significant improvements. Conclusion These pilot data provide compelling preliminary evidence that a single-session IRT intervention modified with NT (N-IRT) is effective in reducing nightmare frequency and intensity, reducing nightmare distress, improving the act of coping with nightmares, and improving sleep quality and overall PTSD symptoms in veterans. Further investigation of this method with gold-standard clinical trial designs and larger sample sizes is indicated to confirm effectiveness and to better understand the possible mechanisms of treatment effect.

Abstract Introduction Prevalence of untreated sleep apnea among veterans is 22.2 %. Untreated patients are at risk for multiple adverse outcomes including chronic sleep deprivation, excessive day time sleepiness, chronic fatigue, depression, and cardiovascular complications including hypertension, coronary artery disease, cerebrovascular accidents, pulmonary hypertension as result of increased sympathetic activity during apnea episodes. Nonadherence to PAP therapy within the first week of treatment are up to 50 % of patients who use PAP device during the first week between 12-25 % discontinue by PAP use by year 3. Barriers to PAP use include physical problems with PAP hardware, knowledge gaps, and psychological issues. Methods Veterans from sleep medicine and sleep apnea clinics as well as multiple primary care clinics participated in the PAP adherence group following 6 weeks biopsychosocial model. The intervention included weekly synchronized video encounters of behavior sleep specialist, respiratory therapist and sleep clinic nurse with the targeted group of veterans with sleep apnea and poor PAP adherence. This approach has multiple benefits, including being patient centered, cost effective and efficient with ability to help veterans at various motivational levels, assist 6-10 veterans virtually in 6 one-hour group sessions and easy care coordination. Results A total of 21 veterans with sleep apnea participated in virtual multidisciplinary group to improve PAP adherence between September 2020 and January 2021. Patients PAP adherence before intervention, post intervention and 1year after intervention was evaluated. Percent of patients using PAP >2 hours before intervention was 5 %, immediately after intervention it increased to 20 %, and there was further increase up to 33% after 1 year post. Conclusion A structured multidisciplinary biopsychosocial intervention demonstrated statistically significant improvement in PAP adherence which persisted up till 1 year post intervention. In fact additional improvement of >2 hours of PAP usage was noted in this patient group suggesting possible long term benefit of psychosocial multidisciplinary intervention on PAP adherence. This study also demonstrated efficiency of utilization of virtual/telemedicine platform for psychosocial intervention and brief behavioral therapy. Support (if any)

Abstract Introduction Approximately 30 million adults in United States suffer from obstructive sleep apnea (OSA), with much higher prevalence in veterans. However, the treatment options of sleep apnea are currently limited due to CPAP device shortage, hence, unravelling a significant gap for alternative user-friendly therapeutic options. Neuromuscular stimulation device of the tongue is a novel FDA approved therapy becoming more relevant with the ongoing CPAP device shortage. Methods Neuromuscular stimulation device of tongue procured through regulatory process at VA Minneapolis, is offered to veterans with Mild OSA( AHI 5-15) on home sleep apnea testing.Baseline and post therapy data including patient's snoring, Epworth sleepiness score(ESS),Apnea - Hypopnea Index(AHI) was collected. Post therapy data was collected after initial 6 weeks of at least 20-minute daily followed by maintenance of 2 weeks of twice weekly use. Results A total of 112 patients with Mild OSA were offered the device as an alternative option of treatment during the period of December 2021 to August 2022. Of these, 39 patients completed therapy with mean age of 54.5 years (age ranging from 28y-80y), 36 were males and 3 were females. Among a total of 31 patients who completed their ESS pre and post questionnaire, and 22 patients who had pre and post AHI available, a paired t-test was obtained. In the 31 patients with pre and post ESS, the results of paired t- test showed a mean difference in ESS score of 1.90 with 95% CI (0.55 -3.25) with statistically significant P value of 0.0073. In the 22 patients with pre and post AHI, results of paired t -test showed Mean difference in AHI score of 2.54 with 95% CI (0.24-4.84) with statistically significant P value of 0.0316. Conclusion Findings suggest that the alternative treatment to CPAP provided to patients did result in improvement of Mild OSA both in subjective sleepiness symptoms and objective degree of residual apnea, and hence can be used as a feasible alternative therapy. However, the study is limited by small size (112) with a relatively low response rate from the participants (39), and availability of matched data (ESS -31, AHI -22). Therefore, larger studies are warranted. Support (if any)

Introduction Currently, there are no Food and Drug Administration-approved therapies to treat dementia-related psychosis (DRP). This study investigated the association between using antipsychotics and the anticonvulsant divalproex (sodium valproate) to manage DRP and adverse outcomes. Methods A retrospective case/control matching study evaluated the risk of mortality, extrapyramidal symptoms (EPS), ischemic stroke, and cardiac arrest/ventricular arrhythmia (CA/VA) with ever-use of antipsychotics/divalproex in patients with DRP vs never-use. Results 49 509 patients were included; 76.8% used an antipsychotic/divalproex. Treatment ever-use was associated with an increased risk of all-cause mortality (odds ratio, 1.14; 95% CI, 1.10-1.18) and a smaller increase in the risk of EPS (1.10; 1.00-1.19) relative to never-use (adjusted for matching demographic variables, comorbid conditions, and disability). Conclusions Current agents used for DRP were associated with increased risk of death and adverse outcomes. An increased risk of death was evident within 3 months of antipsychotic/divalproex initiation and persisted with long-term use.

Currently, no agents are approved in the USA to treat dementia-related psychosis. After failure of a nonpharmacologic approach to treatment, antipsychotics or divalproex is often prescribed. We characterized existing treatment patterns in patients with dementia-related psychosis. Medicare claims data from 2008 to 2016 were used to identify patients with dementia-related psychosis. The agents and associated dosages prescribed, time to first use, and patterns of use were evaluated for agents prescribed to treat dementia-related psychosis. In total, 49 509 patients were identified as having dementia-related psychosis. Over three-quarters (76.8%) received an antipsychotic or divalproex. The most prescribed first-line agents were quetiapine (30.5%), risperidone (19.5%), and divalproex (11.2%). More than 80% of patients received a low dose of an agent, and 65.5% switched or discontinued their first-line treatment during a mean follow-up period of 1.8 years. In the absence of US FDA-approved therapies to treat dementia-related psychosis, treatment after behavioral intervention involves frequent use of low-dose antipsychotics or divalproex. The high rate of treatment switching or discontinuation is consistent with current treatment guidelines and suggests a need for an improved, standardized pharmacological approach to treat dementia-related psychosis.

Abstract Introduction Management of restless legs syndrome (RLS, aka Willis-Ekbom Disease) with dopaminergic agents is often complicated by development of augmentation. Clinical practice guidelines and stepwise algorithms suggest that prior to prescribing dopaminergic agents, clinicians should assess iron stores and consider alpha-2-delta agents (e.g. gabapentin). We developed an informatics approach to assess quality of care metrics for RLS management. Methods We used Veterans Affairs (VA) electronic health record data to identify a cohort of patients at a single tertiary care academic VA facility prescribed dopaminergic agents between 01 Jan 2018 to 31 Dec 2019. Patients with any prior codes for Parkinson’s disease were excluded. A random sample of charts were manually reviewed to determine if dopaminergic drugs were being prescribed for RLS or other indications. We then assessed for evidence of prior iron store assessments, iron repletion if appropriate, and alpha-2-delta agents (gabapentin, pregabalin). Results We identified 1160 patients treated with dopaminergic agents and no prior Parkinson’s codes. Chart reviews indicated 95% accuracy of this methodology to identify dopaminergic use for RLS. Evidence of pre-treatment iron storage assessment was missing in 30.2% for ferritin and 33.5% for transferrin saturation. Among those with iron studies present, lack of iron replacement was noted in 34% of those with ferritin <75 mcg/L and 33% of those with transferrin saturation <20%. Prior or concomitant prescriptions of alpha-2-delta agents was present in 59.7% of the cohort. Conclusion Our informatics approach provides an accurate and efficient means to quantify RLS care metrics. Results were most notable for a high proportion of dopaminergic-treated RLS patients without iron assessments and without iron repletion when stores were low. This methodology will inform future quality improvement initiatives to improve the delivery of guideline concordant RLS care. Support (If Any) This material is the result of work supported with resources and the use of facilities at the Minneapolis Veterans Affairs Health Care System, Minneapolis/USA.

Sleepiness is a commonly encountered complaint in both the primary care and sleep clinic settings. Sleep related breathing disorders are relatively frequent in the United States population and are also a common cause of excessive sleepiness. Understanding the distinction between normal physiological sleepiness and pathologically excessive daytime sleepiness, and distinguishing sleepiness from related problems such as fatigue, are the first steps in making an accurate diagnosis. The focus of this article will be to review the role of sleep related breathing disorders in hypersomnolence, and to review the differential diagnoses for hypersomnolence. In addition to a thorough clinical history and physical exam, there are validated patient questionnaires and subjective sleep reports that are helpful in identifying large deviations from normal sleep habits. When further objective testing is required, portable or sleep lab-based studies, in addition to adjunctive laboratory testing, may further elucidate the clinical picture. With a thorough clinical history and appropriate testing in select patients, the proper diagnosis can quickly be determined. Once a diagnosis has been established, there are a multitude of well-established, new, and emerging therapeutic options available.