Sleep architecture based on sleep depth and propensity: patterns in different demographics and sleep disorders and association with health outcomes

Magdy Younes, Bethany Gerardy, Allan I Pack, Samuel T Kuna, Cecilia Castro-Diehl, Susan Redline, Magdy Younes, Bethany Gerardy, Allan I Pack, Samuel T Kuna, Cecilia Castro-Diehl, Susan Redline

Abstract

Study objectives: Conventional metrics of sleep quantity/depth have serious shortcomings. Odds-Ratio-Product (ORP) is a continuous metric of sleep depth ranging from 0 (very deep sleep) to 2.5 (full-wakefulness). We describe an ORP-based approach that provides information on sleep disorders not apparent from traditional metrics.

Methods: We analyzed records from the Sleep-Heart-Health-Study and a study of performance deficit following sleep deprivation. ORP of all 30-second epochs in each PSG and percent of epochs in each decile of ORPs range were calculated. Percentage of epochs in deep sleep (ORP < 0.50) and in full-wakefulness (ORP > 2.25) were each assigned a rank, 1-3, representing first and second digits, respectively, of nine distinct types ("1,1", "1,2" … "3,3"). Prevalence of each type in clinical groups and their associations with demographics, sleepiness (Epworth-Sleepiness-Scale, ESS) and quality of life (QOL; Short-Form-Health-Survey-36) were determined.

Results: Three types ("1,1", "1,2", "1,3") were prevalent in OSA and were associated with reduced QOL. Two ("1,3" and "2,3") were prevalent in insomnia with short-sleep-duration (insomnia-SSD), but only "1,3" was associated with poor sleep depth and reduced QOL, suggesting two phenotypes in insomnia-SSD. ESS was high in types "1,1" and "1,2", and low in "1,3" and "2,3". Prevalence of some types increased with age while in others it decreased. Other types were either rare ("1,1" and "3,3") or high ("2,2") at all ages.

Conclusions: The proposed ORP histogram offers specific and unique information on the underlying neurophysiological characteristics of sleep disorders not captured by routine metrics, with potential of advancing diagnosis and management of these disorders.

Keywords: Epworth sleepiness scale; ORP; insomnia; obstructive sleep apnea; odds ratio product; quality of life; sleep architecture.

© Sleep Research Society 2022. Published by Oxford University Press on behalf of the Sleep Research Society.

Figures

Figure 1.
Figure 1.
Records from one subject from the Sleep Heart Health Study. (A) Nine 30-second EEG tracings representing EEG patterns receiving ORP values spanning the entire ORP range (0.00–2.50). Epochs with ORP > 1.75 are typically scored wake but exhibit a wide spectrum from full wakefulness with high ORP (top panel) to patterns with sleep features (theta activity and micro-sleep) but do not meet the criteria of sleep. Likewise, a wide range of patterns can be identified in epochs typically scored NREM sleep. The figure shows ORP values ranging 0.36–1.77 within stage N2. (B) Conventional sleep stages in the same subject showing normal values. (C) The proposed ORP-based architecture in which % of epochs occurring within each ORP decile is illustrated. Deciles 1 and 2 represent very deep and deep sleep, respectively (cf. A, two bottom epochs). Decile 3 is moderate sleep and decile 4 is light sleep. Deciles 5–7 are transitional states with progressively increasing wake features (alpha-beta rhythms). Deciles 8 and 9 represent epochs typically scored wake but with sleep features. Decile 10 is seen in full wakefulness (A, top panel).
Figure 2.
Figure 2.
Four architecture patterns randomly found in SHHS participants showing different relations between % of epochs in deep sleep (deciles 1 and 2) and full wakefulness. Participant 1, both ends of the spectrum are low. Participant 2, deep sleep is low while decile 10 is high. Participant 3, much deep sleep with very little full wakefulness. Participant 4, many epochs both in deep sleep and full wakefulness. TRT, total recording time.
Figure 3.
Figure 3.
Compressed full night studies from three SHHS participants illustrating the Cumulative Sleep index (CSI, area between full wakefulness (ORP = 2.5) line and the epoch-by epoch ORP tracing). In practice this is calculated from [(2.50 – ORP in total recording time (TRT)) multiplied by TRT in minutes]. The corresponding conventional histograms are also shown. Note the marked difference in CSI between the three studies. ORP, odds ratio product; REM, rapid eye movement sleep; N1, N2, and N3 are stages 1–3 of non-REM sleep.
Figure 4.
Figure 4.
(A) Changes in ORP-architecture with age (A), gender (B), and body mass index (BMI, C) in participants with “No OSA/Insomnia” in the Sleep Heart Health Study. Abscissa values are the odds ratio product (ORP) deciles, with decile 1 representing the deepest sleep (0.00–0.25), and decile 10 representing full wakefulness (ORP > 2.25). The different groups at each decile were compared by one-way analysis of variance (ANOVA). If p < .05, each group within the same decile was compared to the first group (youngest in the case of age) using the independent t-test with appropriate Bonferroni correction. Significant differences from the first group are indicated by letters: “a”, p ≤ .05; “b”, p ≤ .01; “c”, p ≤ .001; “d”, p ≤ .0001. CSI, Cummulative Sleep Index.
Figure 5.
Figure 5.
(A) and (B) Odds ratio product (ORP) architecture in 200 healthy participants in overnight polysomnograms before and following 36 h of sleep deprivation. Note the remarkable leftward shift in the distribution. (C) and (D) Comparison of ORP-architecture in the first and second halves of the night in Sleep Heart Health Study (SHHS) subjects with “No OSA/Insomnia”. An opposite shift is evident.↓ and↑, significant increase or decrease relative the same decile in the reference panel (p < 1.E−10). PSG, polysomnogram.
Figure 6.
Figure 6.
Changes in ORP-architecture (ORP = odds ratio product) with increasing obstructive apnea (OSA) severity (A), different types of insomnia (B), and in participants with insomnia plus OSA (C). AHI, apnea hypopnea index; NSD, normal sleep duration; SSD, short sleep duration. Abscissa values are the ORP deciles, with decile 1 representing the deepest sleep (0.00–0.25), and decile 10 representing full wakefulness (ORP > 2.25). The different groups at each decile were compared by one-way analysis of variance (ANOVA). If p < .05, each group within the same decile was compared to the first group using the independent t-test with appropriate Bonferroni correction. Significant differences from the first group are indicated by letters: “a”, p ≤ .05; “b”, p ≤ .01; “c”, p ≤ .001; “d”, p ≤ .0001.
Figure 7.
Figure 7.
Average ORP-architecture in the nine pre-selected types. Number of subjects ranged 73–957 in the different types. The two numbers in the Type designation indicate the quartiles in which % of epochs in deep sleep (ORP

Figure 8.

(A) Scatter plot of the…

Figure 8.

(A) Scatter plot of the relation between % epochs in transitional sleep (odds…

Figure 8.
(A) Scatter plot of the relation between % epochs in transitional sleep (odds ratio product (ORP) 1.00–1.75) and % of epochs in stage N1 of NREM sleep. (B) Scatter plot of the relation between % epochs with ORP 2.25) and % wake time.

Figure 9.

Prevalence of different ORP types…

Figure 9.

Prevalence of different ORP types in different age groups of participants with “No…

Figure 9.
Prevalence of different ORP types in different age groups of participants with “No OSA/Insomnia” in both cohorts (Twins and Sleep Heart Health Study). Lines are upper margin of error (95% confidence interval). Solid circles, values found in participants with severe (grey circle), and very severe OSA (black circles) in the different ORP types (From Table 3). White stars, values found in participants with insomnia and short sleep duration (From Table 3). Dark stars, values found in participants with insomnia plus OSA (from Table 3). All symbols are plotted against the 55–70 age group (grey columns) since average age in all clinical groups fell in this range. Where no symbols are shown above a given ORP type, the prevalence of the type is within the confidence interval of participants with no OSA or insomnia.
All figures (9)
Figure 8.
Figure 8.
(A) Scatter plot of the relation between % epochs in transitional sleep (odds ratio product (ORP) 1.00–1.75) and % of epochs in stage N1 of NREM sleep. (B) Scatter plot of the relation between % epochs with ORP 2.25) and % wake time.
Figure 9.
Figure 9.
Prevalence of different ORP types in different age groups of participants with “No OSA/Insomnia” in both cohorts (Twins and Sleep Heart Health Study). Lines are upper margin of error (95% confidence interval). Solid circles, values found in participants with severe (grey circle), and very severe OSA (black circles) in the different ORP types (From Table 3). White stars, values found in participants with insomnia and short sleep duration (From Table 3). Dark stars, values found in participants with insomnia plus OSA (from Table 3). All symbols are plotted against the 55–70 age group (grey columns) since average age in all clinical groups fell in this range. Where no symbols are shown above a given ORP type, the prevalence of the type is within the confidence interval of participants with no OSA or insomnia.

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