Indian Journal of Sleep Medicine

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2021 | July-September | Volume 16 | Issue 3

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Anuja A Deshpande, Mariya P Jiandani, Amita U Athavale

Correlation of Sleep Quality with Cognition, Exercise Capacity, and Fatigue in Patients with Chronic Respiratory Diseases

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:4] [Pages No:61 - 64]

Keywords: Chronic respiratory diseases, Cognition, Exercise capacity, Fatigue, Sleep quality

   DOI: 10.5005/jp-journals-10069-0081  |  Open Access |  How to cite  | 


Background: Sleep is an important component for person's well-being. It is a basic human need.1 Studies have reported increased incidence of cognitive errors and increased fatigue in sleep-deprived normal individuals after 8 hours of work.2 Sleep quality is known to be affected in COPD patients but less studied in other chronic respiratory diseases though the symptoms may be the same. This study aims to assess sleep quality in patients suffering from both COPD and non-COPD respiratory conditions and correlate sleep quality with cognition, exercise capacity, and fatigue in patients with chronic respiratory diseases. Material and methodology: An observational cross-sectional study consisting of 142 stable chronic respiratory disease patients was conducted from September 2016 to March 2017. Sleep quality was evaluated using Pittsburgh sleep quality index (PSQI), cognition using montreal cognitive assessment (MoCA), exercise capacity was measured with incremental shuttle walk test, and fatigue with fatigue severity scale (FSS). Results: Spearman's test was used to assess correlation of sleep quality with cognition, exercise capacity, and fatigue. Significant but very weak and poor inverse correlation of sleep quality was found with cognition and exercise capacity, respectively, whereas there was weak and linear correlation of sleep quality with fatigue. There was no significant difference in sleep quality of COPD and non-COPD patients as well as hypoxemic and non-hypoxemic patients. Conclusion: Though there is very weak correlation of sleep quality with cognition, sleep quality is poor in 55.63% of patients and cognition is affected in 93.6% of patients (n = 133). Clinical significance: Sleep quality should be assessed regularly as a part of primary assessment in all chronic respiratory disease patients. Key Message: Evaluation of sleep quality must be included in routine assessment of patients with chronic respiratory diseases.



Priya Ramachandran, Kimberley D Souza, Uma Devaraj, Uma Maheshwari, George D Souza

Assessing Cognitive Impairment in Patients with Sleep-disordered Breathing Using Mini-mental State Score and Addenbrooke's Cognitive Examination—Revised

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:4] [Pages No:65 - 68]

Keywords: Addenbrooke's cognitive examination—revised, Mild cognitive impairment, Mini-mental state score, Obstructive sleep apnea

   DOI: 10.5005/jp-journals-10069-0082  |  Open Access |  How to cite  | 


Aims and objectives: Obstructive sleep apnea (OSA), which is by far the most common form of sleep-disordered breathing, is associated with many other adverse health consequences including cognitive impairment. The screening methods for cognitive impairment in subjects with OSA are not well recognized. Mini-mental state score (MMSE) is the most widely used screening tool. This study was done to evaluate the utility of Addenbrooke's cognitive examination—revised (ACE-R) in comparison to MMSE. Methodology and results: Thirty-six cases and controls [Epworth sleepiness score (ESS<10)] were recruited. They were administered using MMSE and ACE-R along with the online simulation test. The average age of both cases and controls was 49.2. Fourteen (58%) subjects had an MMSE score of less than 24, and 30 (81%) subjects had an ACE-R score of less than 82 thus qualifying for mild cognitive impairment (MCI). None of the controls had MCI. All subjects had severe OSA. The sleep parameters like apnea–hypopnea index (AHI), oxygen desaturation index (ODI), lowest saturation, and ESS had a negative correlation though not significant. Reaction time on the online simulator was increased in OSA as compared to controls. Conclusion: The ACE-R can be used for screening for the presence of MCI in subjects with OSA and is a better screening tool than MMSE.



Nalin T Shah

A Predictive Performance of STOP-BANG Score and Epworth Sleepiness Scale in Suspected Sleep Apnea Individuals

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:8] [Pages No:69 - 76]

Keywords: Apnea–Hypopnea Index, Epworth sleepiness scale, Obstructive sleep apnea, obese, gender and age, Snoring, STOP-BANG questionnaire

   DOI: 10.5005/jp-journals-10069-0083  |  Open Access |  How to cite  | 


Background: Incidence of sleep apnea is rising globally. STOP-BANG (Snoring, Tiredness, Observed choking, Pressure, Body Mass Index (BMI), Age, Neck girth, Gender) Score and Epworth sleepiness scale (ESS) are outpatient assessment scores available to suspect and estimate the severity of obstructive sleep apnea (OSA) that is compared with gold standard test overnight polysomnography. Objective: The objective of the article was to validate and establish a correlation of variables of STOP-BANG Score, ESS, and Apnea–Hypopnea Index (AHI) from polysomnography. Methods: Retrospective study in patients aged 18 or more who were referred to the Department of Pulmonary Medicine, BJMC, Ahmedabad, between April 2017 and December 2020 who had complaints of excessive daytime sleepiness underwent overnight polysomnography after physical examination in the outpatient department. Results: Of our study population (n = 200), number of men were 137 (68.5%) and women were 63 (31.5%) with a male:female ratio of 2.17:1. Mean BMI, neck girth, ESS, STOP-BANG Score, and AHI were 32.78 ± 6.9 kg/m2, 39.49 ± 5.97 cm, 14.48 ± 3.91, 5.34 ± 1.7, and 48.22 ± 23, respectively, and the number of patients according to severity was mild 16 (8%), moderate 36 (18%), and severe 146 (73%). The Pearson correlation counted between neck girth (r = 0.68), ESS (r = 0.73) and STOP-BANG Score (r = 0.55) with AHI with a significant p value (<0.0001). Conclusion: Snoring is the most common symptom in suspected OSA individuals. The study showed a positive correlation of BMI, neck girth, ESS >10, STOP-BANG Score >3 with severity of OSA depicted in polysomnography.



Arpita C Halder

Comparison of Sleep and Respiratory Parameters of Obstructive Sleep Apnea Patients during Diagnostic and 2 Hours Automatic Positive Airway Pressure Split-night Titration: A Descriptive Study

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:5] [Pages No:77 - 81]

Keywords: Automatic positive airway pressure titration, Continuous positive airway pressure titration, Obstructive sleep apnea, Polysomnography, Split-night study

   DOI: 10.5005/jp-journals-10069-0076  |  Open Access |  How to cite  | 


Aims and objectives: Obstructive sleep apnea (OSA) is a common disorder manifested with snoring, daytime sleepiness, fatigue, metabolic, and cardiovascular symptoms. Manual continuous positive airway pressure (CPAP) titration is the gold standard to determine the amount of positive pressure required to abolish the airflow limitations. The current American Academy of Sleep Medicine (AASM) criteria for manual titration are very stringent, elegant but difficult. The AASM protocol does not favor the use of automatic positive airway pressure (APAP) in a split-night study. This study was done to look into changes in sleep and respiratory parameters following diagnostic polysomnography (PSG) and subsequent APAP titration, as a split-night protocol. Materials and method: Records of 80 patients were scrutinized who had done level 1 PSG in a sleep laboratory in Kolkata, India. The laboratory used APAP titration for all kinds of titrations. This is a descriptive study, where data were compared between diagnostic and therapeutic nights of the same patients, done as a split-night study. Results: The diagnostic night was denoted by visit 1 and therapeutic night as visit 2; the study was done as a split-night study. The rapid eye movement (REM) sleep time was found to be significantly increased from 15.08 minutes in V1 (SD 16.26) to 29.69 minutes (24.45) in V2 with a p <0.001. The total respiratory events were found to be significantly reduced from baseline median value of 206–14 in the follow-up visit posttreatment, p <0.001 as computed by Wilcoxon's signed-rank test. The REM SpO2 was found to be significantly increased from baseline value of 90.87 ± 7.105 to 93.29 ± 6.312 in the follow-up visit posttreatment, p <0.001 as computed by paired sample t-test. Discussion and conclusion: The wake stages, N1 and N2 sleep, were reduced significantly in the therapeutic night than diagnostic night, but N3 sleep was increased in therapeutic night, though statistically not significant. The total arousals and arousal index were also decreased significantly, although there were wide interindividual variations. So overall, patients had an improved sleep architecture during therapeutic night and often with REM rebound. Overall respiratory parameters showed very significant improvement in terms of apnea and hypopnea index (AHI). Oximetry data showed very significant improvements in terms of oxygen saturation, nadir oxygen saturation, and REM time oxygen level. So we can formulate the hypothesis that even a 2 hours split-night APAP titration can perform a good titration and significant improvements in sleep and respiratory parameters.



KR Bharath K Reddy, Rashmi Bhopi, Maya Ramagopal

Evaluation of Sleep Patterns and Practices in Healthy Indian Infants: Is there a Cultural Difference?

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:4] [Pages No:82 - 85]

Keywords: Prevalence, Questionnaire, Sleep practice, Sleep quality

   DOI: 10.5005/jp-journals-10069-0077  |  Open Access |  How to cite  | 


Background: Consolidated sleep through the night plays a critical role in the growth, development, and behavior of a child. There is a need to understand sleep practices in the region to enable parent counseling and developing guidelines for the healthy Indian infants. Objective: The objective of this article was to evaluate sleep patterns and practices in healthy Indian infants. Study design: The cross-sectional study method was used in this study. Participants: Infants aged 1–18 months are the participants of the study. Intervention: Survey using the Brief Infant Sleep Questionnaire (BISQ) was validated as the intervention activity conducted in the study. Outcomes: Duration of night sleep, day sleep, and total sleep time; average bedtime; number and duration of night awakenings; position and location of sleep; sleep initiation process; and parental perception of sleep problem are the final outcomes obtained from this study. Results: The average bedtime was 21:45 p.m., mean total sleep time 11.65 (±1.59) hours, night sleep time 8.58 (±1.70) hours and day sleep time 3.06 (±1.59) hours. The mean number of awakenings was 3.32 (±1.57). 43.6% of the babies slept on their back and 88% of the babies slept in their parents’ bed. 45.6% of the babies needed to be fed, 31.6% rocked, and 15.2% held to sleep. 41.6% of the parents perceived their baby to be having a sleep problem. The babies whose parents perceived no sleep problems, slept longer at night (p <0.001), had lesser night awakenings (p <0.001) and lesser nocturnal wakefulness (p <0.001) compared to those with a serious to small sleep problem. Conclusion: Current sleep practices in India are different than those recommended for Western infants and follow cultural norms. Early problematic sleep habits can become a chronic problem. Early intervention is recommended to prevent that occurrence.



COVID-19 and Obstructive Sleep Apnea

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:4] [Pages No:86 - 89]

Keywords: COVID-19, Endothelial dysfunction, Happy hypoxia, OSA, Oxidative stress, RAAS

   DOI: 10.5005/jp-journals-10069-0080  |  Open Access |  How to cite  | 


Obstructive sleep apnea (OSA) is a disease that manifests with snoring, excessive daytime sleepiness, and fatigue. OSA is the mother of many diseases. COVID-19 is such a disease that can cause greater harm to the patients with OSA. The prevalence of clinically significant OSA where an urgent intervention was required was 6–17% in the adult population, whereas the prevalence was as high as 49% in the advanced age-group. The prevalence of OSA is always more in adult men than in adult women. Expressions of COVID-19 among different peoples are varied. But four main determinants are the following: (1) renin–angiotensin–aldosterone system (RAAS), (2) oxidative stress of the individual, (3) endothelial dysfunction, and (4) immune responses. All of these four systems are in deranged state in OSA patients; they are already in the hyperactive states due to intermittent hypoxia, sympathetic activation, and poor sleep quality. So any acute insult like COVID-19 may throw these systems out of control. The acute “happy hypoxia” of COVID-19 can really be dangerous in the presence of “chronic intermittent happy hypoxia” of OSA.


Short Review

Baljeet S Virk, Priyanka Kapoor, Aman Chowdhry

Pediatric Sleep Apnea: A Multidisciplinary Diagnosis with a Multimodality Treatment

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:3] [Pages No:90 - 92]

Keywords: Benefit, Dental, Multimodality, OSA, Pediatric, Positive airway pressure, Screening, STOP-BANG

   DOI: 10.5005/jp-journals-10069-0079  |  Open Access |  How to cite  | 


Pediatric obstructive sleep apnea (OSA) is an underdiagnosed and often ignored entity. Besides, its management needs a multimodality approach including medical, surgical, dental, and positive airway pressure therapy. This short review discusses the approach, management, and screening options for pediatric OSA along with a glimpse of the latest innovations and the road ahead.



Javed A Siddiqui, Shazia F Qureshi, Adel Allethey, Talal A Mahfouz

Preventive Effect of Lithium on “Kleine–Levin Syndrome”

[Year:2021] [Month:July-September] [Volume:16] [Number:3] [Pages:2] [Pages No:93 - 94]

Keywords: Hyperphagia, Hypersexuality, Hypersomnia, Kleine–Levin syndrome, Lithium, Sleeping beauty

   DOI: 10.5005/jp-journals-10069-0078  |  Open Access |  How to cite  | 


Kleine–Levin syndrome (KLS) is a rare sleep disorder characterized by periodic excessive sleepiness, hyperphagia, hypersexuality, and varying degrees of cognitive and behavioral disturbances. Here, we report a typical case of Kleine–Levin syndrome associated with deterioration of academic performance because of excessive sleepiness. He was started on modafinil and lithium, to which he showed good response.


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