Excessive daytime sleepiness and vascular events: The Three City Study

Prevalence, dimensions, and correlates of excessive daytime sleepiness in community-dwelling older adults: the Yilan study, Taiwan

BACKGROUND

Daytime sleepiness is an important health problem. However, the dimensionality of the Epworth Sleepiness Scale (ESS) in older adults remains unclear. This study aimed to determine the prevalence of ESS-defined excessive daytime sleepiness in older adults. Furthermore, the dimensionality of ESS and its respective correlates were also compared.

MATERIALS AND METHODS

This is a community-based survey in which community-dwelling older adults aged ≥ 65 years participated. Excessive daytime sleepiness was assessed using the ESS and was defined as an ESS score of > 10. Exploratory factor analysis was performed to identify the ESS factors. Multiple logistic regression analysis was used to examine the independent correlates of the ESS-defined and factor-specific correlates of excessive daytime sleepiness.

RESULTS

In total, 3978 older adults participated in this study. The mean age was 76.6 ± 6.7 years, with 53.8% ≥ 75 years, and 57.1% were female. The prevalence of ESS-defined excessive daytime sleepiness was 16.0%. An exploratory factor analysis revealed two factors in the ESS, which were designated as 'passive' and 'active' according to the soporific levels of ESS items loaded in each factor. Multiple logistic regression showed that male, illiteracy, depression, disability, short sleep duration and no exposure to hypnotics were risk indicators for ESS-defined excessive daytime sleepiness. However, the correlates for passive and active factor-defined excessive daytime sleepiness differ in pattern, especially in variables related to education, exercise, mental health, and sleep.

CONCLUSIONS

The prevalence of ESS-defined excessive daytime sleepiness is high, and its correlates vary among older adults. This study also suggests a dual ESS structure in community-dwelling older adults.

Naps and cardiovascular disease risk in different age and sex groups: evidence from a large community cohort

STUDY OBJECTIVES

This study examined the relationship between naps and cardiovascular disease (CVD) events or death in different age and sex groups.

METHODS

A total of 3,069 participants stratified by age (< 65, 65-74, and ≥ 75 years old) and sex, underwent Cox regression analysis to assess nap's impact on CVD risk. Restricted cubic spline plots were used for dose-response relationships.

RESULTS

Significant age-stratified interactions were found when exploring the associations between nap frequency or duration and CVD events (Pinteraction = .001, .036, respectively). Individuals younger than 65 years with higher nap frequency or longer nap duration had a significantly increased risk of CVD events (P < .001, P = .001, respectively). The age group of 65-74 years showed significant associations between CVD events and nap frequency or nap duration (P = .017, .016, respectively), together with nap duration and CVD deaths (P = .008). In the subgroup of females aged 65-74, significant associations were found between nap frequency or duration and CVD events (P = .006, .002, respectively). Nap frequency or duration was also significantly associated with CVD deaths (P = .005, .010 respectively).

CONCLUSIONS

This study underscores a noteworthy correlation between a higher frequency or longer duration of daytime nap and an increased susceptibility to CVD among individuals aged 65-74 years, particularly in females. However, further research is needed to better understand the underlying mechanisms.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Sleep Heart Health Study; URL: https://clinicaltrials.gov/ct2/show/study/NCT00005275; Identifier: NCT00005275.

CITATION

Chen C, Guo Q, Cheng Y, Lan Y, Cheng D, Huang J. Naps and cardiovascular disease risk in different age and sex groups: evidence from a large community cohort. J Clin Sleep Med. 2024;20(8):1339-1348.

Association between longitudinal change of sleep patterns and the risk of cardiovascular diseases

STUDY OBJECTIVES

To investigate the role of longitudinal change of sleep patterns in the incidence of cardiovascular diseases (CVD).

METHODS

Based on UK Biobank, a total of 18 172 participants were enrolled. Five dimensions of healthy sleep including early chronotype, sleep 7-8 hours/day, free of insomnia, no snoring, and no frequent excessive daytime sleepiness were used to generate a healthy sleep score (HSS) ranging from 0 to 5. Corresponding to the HSS of 0-1, 2-3, and 4-5, the poor, intermediate, and healthy sleep patterns were defined. Based on changes in HSS across assessments 1 and 2, we calculated the absolute difference of HSS. For the change in sleep patterns, we categorized five profiles (stable healthy, worsening, stable intermediate, optimizing, and stable poor sleep patterns). The outcomes were incidence of CVD including coronary heart disease (CHD) and stroke. We assessed the adjusted hazard ratios and 95% confidence intervals (CIs) by Cox hazard models.

RESULTS

Compared with participants with stable poor patterns, those who improved their sleep patterns or maintained healthy sleep patterns had a 26% and 32% lower risk of CVD, respectively. Stable healthy sleep pattern was associated with a 29% and 44% reduced risk of CHD and stroke. Per unit, longitudinal increment of the HSS was related to an 8% lower risk of CVD and CHD. Compared with individuals with constant HSS, those with decreased HSS had a 13% higher risk of developing CVD.

CONCLUSIONS

Optimizing sleep patterns and maintaining a healthy sleep pattern may reduce the risk of CVD.

Brain artery diameters and risk of dementia and stroke

INTRODUCTION

We tested the association of brain artery diameters with dementia and stroke risk in three distinct population-based studies using conventional T2-weighted brain magnetic resonance imaging (MRI) images.

METHODS

We included 8420 adults > 40 years old from three longitudinal population-based studies with brain MRI scans. We estimated and meta-analyzed the hazard ratios (HRs) of the brain and carotids and basilar diameters associated with dementia and stroke.

RESULT

Overall and carotid artery diameters > 95th percentile increased the risk for dementia by 1.74 (95% confidence interval [CI], 1.13-2.68) and 1.48 (95% CI, 1.12-1.96) fold, respectively. For stroke, meta-analyses yielded HRs of 1.59 (95% CI, 1.04-2.42) for overall arteries and 2.11 (95% CI, 1.45-3.08) for basilar artery diameters > 95th percentile.

DISCUSSION

Individuals with dilated brain arteries are at higher risk for dementia and stroke, across distinct populations. Our findings underline the potential value of T2-weighted brain MRI-based brain diameter assessment in estimating the risk of dementia and stroke.

Can intraoral and facial photos predict obstructive sleep apnea in the general and clinical population?

STUDY OBJECTIVES

This study aimed to evaluate and compare measurements of standardized craniofacial and intraoral photographs between clinical and general population samples, between groups of individuals with an apnea-hypopnea index (AHI) ≥ 15 and AHI < 15, and their interaction, as well as the relationship with the presence and severity of obstructive sleep apnea (OSA).

METHODS

We used data from 929 participants from Sleep Apnea Global Interdisciplinary Consortium, in which 309 patients from a clinical setting and 620 volunteers from a general population.

RESULTS

AHI ≥ 15 were observed in 30.3% of the total sample and there were some interactions between facial/intraoral measures with OSA and both samples. Mandibular volume (p < 0.01) and lateral face height (p = 0.04) were higher in the AHI ≥ 15 group in the clinical sample compared to the AHI ≥ 15 group in the general population and AHI < 15 group in the clinical sample. When adjusted for sex and age, greater mandible width (p < 0.01) differed both in the clinical and in the general population samples, reflecting AHI severity and the likelihood of OSA. The measure of smaller tongue curvature (p < 0.01) reflected the severity and probability of OSA in the clinical sample and the higher posterior mandibular height (p = 0.04) showed a relationship with higher AHI and higher risk of OSA in the general population. When adjusted for sex, age, and body mass index, only smaller tongue curvature (p < 0.01) was associated with moderate/severe OSA.

CONCLUSIONS

Measures of greater tongue and mandible were associated with increased OSA risk in the clinical sample and craniofacial measurement was associated in the general population sample.

The differential pattern of associations between nighttime sleep disturbances with dimensions of daytime sleepiness in community-dwelling older adults, the Yilan study, Taiwan

BACKGROUND

The association between nighttime sleep disturbance and daytime sleepiness remains unclear. This study aimed to examine the relationships between various domains of nighttime sleep disturbance, daytime sleepiness, and their specific dimensions.

METHODS

This was a community-based cross-sectional study. The participants were adults aged 65 years and older from Yilan City, Taiwan. Daytime sleepiness (DS) was defined using the Epworth Sleepiness Scale (ESS) with scores ≥ 11. The ESS dimensions were further examined using exploratory factor analysis. The highest 15% factor scores for each factor were defined as factor-specific DS. Various domains of nighttime sleep disturbance were assessed using the Pittsburgh Sleep Quality Index. Logistic regression analysis was used to examine the independent relationships among various nighttime sleep disturbances, ESS, and its dimensions.

RESULTS

Of the 2585 participants, a total of 59.0% were women. Two factors were identified by exploratory factor analysis and were designated as 'passive factor' and 'active factor'. Multiple logistic regression analyses elucidated that short sleep duration was a common risk indicator for ESS-defined (odds ratio (OR): 2.01; 95% confidence interval (CI): 1.43-2.83), passive factor-defined (OR: 2.23, 95% CI: 1.65-3.00), and active factor-defined DS (OR: 1.47, 95% CI: 1.07-2.00). Hypnotic use was associated with a lower risk of both ESS-defined (OR: 0.66, 95% CI: 0.47-0.92) and passive factor-defined DS (OR:0.69, 95% CI: 0.52-0.92). Bathroom use (OR: 1.41, 95% CI: 1.04-1.91), coughing or snoring (OR: 2.14, 95% CI: 1.01-4.56), and sleep efficiency (OR: 0.42; 95% CI: 0.31-0.57) were uniquely associated with active factor-defined DS.

CONCLUSION

Two factors were identified in the ESS, revealing factor-specific correlates of DS. Specifically, ESS- and passive factor-defined DS shared similar correlates. In contrast, some correlates seem unique to active-factor-defined DS.

Association of sleep characteristics with cardiovascular disease risk in adults over 40 years of age: a cross-sectional survey

Background

The relationship between sleep characteristics and cardiovascular disease (CVD) risk has yet to reach a consistent conclusion, and more research needs to be carried out. This study aimed to explore the relationship between snoring, daytime sleepiness, bedtime, sleep duration, and high-risk sleep patterns with CVD risk.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 2015-2018 were collected and analyzed. Multivariable logistic regression was used to evaluate the relationship between snoring, daytime sleepiness, bedtime, sleep duration, high-risk sleep patterns, and CVD risk. Stratified analysis and interaction tests were carried out according to hypertension, diabetes and age.

Results

The final analysis contained 6,830 participants, including 1,001 with CVD. Multivariable logistic regression suggested that the relationship between snoring [OR = 7.37,95%CI = (6.06,8.96)], daytime sleepiness [OR = 11.21,95%CI = (9.60,13.08)], sleep duration shorter than 7 h [OR = 9.50,95%CI = (7.65,11.79)] or longer than 8 h [OR = 6.61,95%CI = (5.33,8.19)], bedtime after 0:00 [OR = 13.20,95%CI = (9.78,17.80)] compared to 22:00-22:59, high-risk sleep patterns [OR = 47.73,95%CI = (36.73,62.04)] and CVD risk were statistically significant. Hypertension and diabetes interacted with high-risk sleep patterns, but age did not.

Conclusions

Snoring, daytime sleepiness, excessive or short sleep duration, inappropriate bedtime, and high-risk sleep patterns composed of these factors are associated with the CVD risk. High-risk sleep patterns have a more significant impact on patients with hypertension and diabetes.

Sleep patterns and risks of incident cardiovascular disease and mortality among people with type 2 diabetes: a prospective study of the UK Biobank

BACKGROUND

To explore the relationship between sleep patterns and cardiovascular disease (CVD) incidence and mortality risk in a population with type 2 diabetes through a UK Biobank sample.

METHODS

A total of 6860 patients with type 2 diabetes were included in this study. Five sleep factors (including Chronotype, sleep duration, insomnia, daytime sleepiness, and snoring) were collected as a questionnaire. The calculation generates a sleep score of 0-5, and then three sleep patterns were defined based on the sleep scores: poor sleep pattern (0-2), Intermediate sleep pattern (3-4), and healthy sleep pattern (5). HRs and 95% confidence intervals were calculated by multivariate COX proportional risk model adjustment. Restricted cubic splines were used to validate linear associations between sleep scores CVD events.

RESULTS

Our results found a reduced risk of CVD events in individuals with healthy sleep patterns compared to participants with poor sleep patterns. CVD Mortality (HR, 0.690; 95% CI 0.519-0.916), ASCVD (Atherosclerosis CVD) (HR, 0.784; 95% CI 0.671-0.915), CAD (Coronary Artery Disease) (HR, 0.737; 95% CI 0.618-0.879), PAD (Peripheral Arterial Disease) (HR, 0.612; 95% CI 0.418-0.896), Heart Failure (HR, 0.653; 95% CI 0.488-0.875). Restricted cubic spline responded to a negative linear correlation between sleep scores and CVD Mortality, ASCVD, CAD, PAD, and Heart Failure.

CONCLUSIONS

Healthy sleep patterns are significantly associated with a reduced risk of CVD Mortality, ASCVD, CAD, PAD, and Heart Failure in the diabetes population.

Different dimensions of daytime sleepiness predicted mortality in older adults: Sex and muscle power-specific risk in Yilan Study, Taiwan

OBJECTIVES

This study aimed to investigate the relationship between daytime sleepiness and mortality risk among older adults. The moderating effects of sex and physical function were examined.

METHODS

This 9-year follow-up study was conducted with community-dwelling individuals aged ≥65 years. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale (ESS). Exploratory factor analysis (EFA) was used to examine the ESS factors. Handgrip strength was measured to assess physical function, and the highest quartile was defined as good muscle power. Cox regression analysis was used to estimate the 9-year all-cause mortality risk. The interaction terms were examined to evaluate their moderating effect.

RESULTS

In total, 2588 individuals participated in the study. The EFA explored two factors: the passive factor (PF) and the active factor (AF). After controlling for various covariates, the cutoff-defined daytime sleepiness (ESS≥11), total raw scores, and factor scores of the ESS all failed to predict mortality risk. The 3-way interaction terms showed statistical significance in terms of [sex × PF × muscle power (p = 0.03)] but not for [sex × AF × muscle power (p = 0.11)]. Specifically, PF predicted mortality risk in women with good muscle power (hazard ratio (HR): 1.48; 95 % confidence interval (CI): 1.04-2.10), which is female-specific. In contrast, AF predicted mortality risk only in men with good muscle power (HR: 1.35; 95 % CI: 1.02-1.78).

CONCLUSIONS

The ESS-measured daytime sleepiness in older adults is multidimensional. The mortality risk for each dimension was determined based on sex and physical function.

Causal Association Between Subtypes of Excessive Daytime Sleepiness and Risk of Cardiovascular Diseases

BACKGROUND

Excessive daytime sleepiness (EDS), experienced in 10% to 20% of the population, has been associated with cardiovascular disease and death. However, the condition is heterogeneous and is prevalent in individuals having short and long sleep duration. We sought to clarify the relationship between sleep duration subtypes of EDS with cardiovascular outcomes, accounting for these subtypes.

METHODS AND RESULTS

We defined 3 sleep duration subtypes of excessive daytime sleepiness: normal (6-9 hours), short (<6 hours), and long (>9 hours), and compared these with a nonsleepy, normal-sleep-duration reference group. We analyzed their associations with incident myocardial infarction (MI) and stroke using medical records of 355 901 UK Biobank participants and performed 2-sample Mendelian randomization for each outcome. Compared with healthy sleep, long-sleep EDS was associated with an 83% increased rate of MI (hazard ratio, 1.83 [95% CI, 1.21-2.77]) during 8.2-year median follow-up, adjusting for multiple health and sociodemographic factors. Mendelian randomization analysis provided supporting evidence of a causal role for a genetic long-sleep EDS subtype in MI (inverse-variance weighted β=1.995, P=0.001). In contrast, we did not find evidence that other subtypes of EDS were associated with incident MI or any associations with stroke (P>0.05).

CONCLUSIONS

Our study suggests the previous evidence linking EDS with increased cardiovascular disease risk may be primarily driven by the effect of its long-sleep subtype on higher risk of MI. Underlying mechanisms remain to be investigated but may involve sleep irregularity and circadian disruption, suggesting a need for novel interventions in this population.

Association of healthy sleep pattern with risk of recurrent cardiovascular events among patients with coronary heart disease

AIMS

To examine the association of a healthy sleep pattern with the risk of recurrent cardiovascular events among patients with coronary heart disease (CHD).

METHODS AND RESULTS

This prospective cohort study included 21 193 individuals with CHD from the UK Biobank. A healthy sleep score was generated based on a combination of chronotype, sleep duration, insomnia, and excessive daytime sleepiness. Cox proportional hazards regression models were applied to estimate the associations between healthy sleep score and recurrent cardiovascular events. During a median of 11.1 years of follow up, we documented 3771 recurrent cardiovascular events, including 1634 heart failure cases and 704 stroke cases. After multivariable adjustment, including lifestyle factors, medical history, and CHD duration, sleep 7-8 h/day, never/rarely insomnia, and no frequent daytime sleepiness were each significantly associated with a 12-22% lower risk of heart failure. In addition, compared with participants who had a healthy sleep score of 0-1, the multivariable-adjusted HR (95% CI) for participants with a healthy sleep score of 4 was 0.86 (0.75, 0.99) for recurrent cardiovascular events, 0.71 (0.57, 0.89) for heart failure, and 0.72 (0.51, 1.03) for stroke.

CONCLUSIONS

Adherence to a healthy sleep pattern was significantly associated with a lower risk of recurrent cardiovascular events among patients with CHD, especially for heart failure. These findings indicate that healthy sleep behaviours could be beneficial in the prevention of cardiovascular event recurrence.

The multifaceted aspects of sleep and sleep-wake disorders following stroke

Sleep-wake disorders (SWD) are acknowledged risk factors for both ischemic stroke and poor cardiovascular and functional outcome after stroke. SWD are frequent following stroke, with sleep apnea (SA) being the most frequent SWD affecting more than half of stroke survivors. While sleep disturbances and SWD are frequently reported in the acute phase, they may persist in the chronic phase after an ischemic stroke. Despite the frequency and risk associated with SWD following stroke, screening for SWD remains rare in the clinical setting, due to challenges in the assessment of post-stroke SWD, uncertainty regarding the optimal timing for their diagnosis, and a lack of clear treatment guidelines (i.e., when to treat and the optimal treatment strategy). However, little evidence support the feasibility of SWD treatment even in the acute phase of stroke and its favorable effect on long-term cardiovascular and functional outcomes. Thus, sleep health recommendations and SWD treatment should be systematically embedded in secondary stroke prevention strategy. We therefore propose that the management of SWD associated with stroke should rely on a multidisciplinary approach, with an integrated diagnostic, treatment, and follow-up strategy. The challenges in the field are to improve post-stroke SWD diagnosis, prognosis and treatment, through a better appraisal of their pathophysiology and temporal evolution.

Daytime napping and coronary heart disease risk in adults: a systematic review and dose-response meta-analysis

PURPOSE

The present study investigated the association between daytime napping and coronary heart disease (CHD) risk among adults.

METHODS

Articles were detected by using PubMed, ISI Web of Science, and Scopus databases until November 8th, 2021. The relevant data were found among the eight included articles and were pooled for meta-analysis in adult participants via a random-effects model.

RESULTS

Among 167,025 adults, the results revealed that daytime napping was associated with an enhanced risk of CHD (risk ratios [RR] = 1.30; 95% CI: 1.06, 1.60; p < 0.001). Subgroup analysis by daytime napping duration also indicated that daytime napping for at least 1 h had three times higher influence on the enhanced risk of CHD (RR = 1.34; 95% CI: 1.14, 1.58; p < 0.001) than that of daytime napping for less than 1 h (RR = 1.10; 95% CI: 1.02, 1.19; p = 0.014). In addition, subgroup analysis by region illustrated that daytime napping was linked with an enhanced risk of CHD in Chinese (RR = 1.41; 95% CI: 1.19, 1.66; p < 0.001), but not in European or American populations. Furthermore, the subgroup analysis of napping duration and risk of CHD suggested that their relation was significant just in those studies that controlled for depressive symptoms (RR = 1.52; 95% CI: 1.29, 1.80; p < 0.001, n = 3) and night sleep duration (RR = 1.42; 95% CI: 1.21, 1.66; p < 0.001, n = 5). The linear dose-response meta-analysis revealed that each 15-min increase in daytime napping was related with a 5% higher risk of CHD (RR = 1.05; 95% CI: 1.02, 1.08; I2 = 58.7%; p < 0.001). Furthermore, nonlinear dose-response meta-analysis revealed a positive linear relationship between daytime napping and CHD risk in adults (p nonlinearity = 0.484, p dose-response = 0.003).

CONCLUSION

Results showed that daytime napping was related with an increased risk of CHD in adults. The evidence from this study suggests that the public should be made conscious of the adverse outcomes of long daytime napping for CHD, notably among the Chinese population. Additional studies are required to confirm potential links between CHD risk and daytime napping.

Louis EK, Chahal AA, Schulte PJ, Mansukhani MP, Xie J, Lipford MC, Li N, Ramar K, Caples SM, Gay PC, Olson EJ, Silber MH, Li J, Somers VK. Sex-specific associations between daytime sleepiness, chronic diseases and mortality in obstructive sleep apnea

Objective

Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA) and has been linked to adverse outcomes, albeit inconsistently. Furthermore, whether the prognostic impact of EDS differs as a function of sex is unclear. We aimed to assess the associations between EDS and chronic diseases and mortality in men and women with OSA.

Methods

Newly-diagnosed adult OSA patients who underwent sleep evaluation at Mayo Clinic between November 2009 and April 2017 and completed the Epworth Sleepiness Scale (ESS) for assessment of perceived sleepiness (N = 14,823) were included. Multivariable-adjusted regression models were used to investigate the relationships between sleepiness, with ESS modeled as a binary (ESS > 10) and as a continuous variable, and chronic diseases and all-cause mortality.

Results

In cross-sectional analysis, ESS > 10 was independently associated with lower risk of hypertension in male OSA patients (odds ratio [OR], 95% confidence interval [CI]: 0.76, 0.69-0.83) and with higher risk of diabetes mellitus in both OSA men (OR, 1.17, 95% CI 1.05-1.31) and women (OR 1.26, 95% CI 1.10-1.45). Sex-specific curvilinear relations between ESS score and depression and cancer were noted. After a median 6.2 (4.5-8.1) years of follow-up, the hazard ratio for all-cause death in OSA women with ESS > 10 compared to those with ESS ≤ 10 was 1.24 (95% CI 1.05-1.47), after adjusting for demographics, sleep characteristics and comorbidities at baseline. In men, sleepiness was not associated with mortality.

Conclusion

The implications of EDS for morbidity and mortality risk in OSA are sex-dependent, with hypersomnolence being independently associated with greater vulnerability to premature death only in female patients. Efforts to mitigate mortality risk and restore daytime vigilance in women with OSA should be prioritized.

Complaints of daytime sleepiness, insomnia, hypnotic use, and risk of dementia: a prospective cohort study in the elderly

Background

Sleep disturbances are common in elderly and occur frequently in dementia. The impact of excessive daytime sleepiness (EDS), insomnia complaints, sleep quality, and hypnotics on the risk of all-cause dementia, Alzheimer disease (AD), and dementia with vascular component (DVC) remains unclear, as does the association between sleep profile and plasma β-amyloid levels.

Methods

Analyses were carried out on 6851 participants aged 65 years and over randomly recruited from three French cities and free of dementia at baseline. A structured interview and self-questionnaire assessed sleep complaints (EDS, insomnia complaints, sleep quality) and medications at baseline. Incident cases of dementia were diagnosed systematically over a 12-year period. Multivariate Cox models were used to estimate the risk of dementia associated with the sleep complaints considered individually and globally. Plasma β-amyloid levels were measured by an xMAP-based assay technology in 984 subjects.

Results

After adjustment for socio-demographic characteristics, lifestyle, APOE-ε4, cardiovascular factors, and depressive status, EDS had a higher risk of all-cause dementia (HR = 1.21; 95%CI = [1.01–1.46]) and DVC (HR = 1.58; 95%CI = [1.07–2.32]) but not AD. Persistent use of hypnotics increased the risk for all-cause dementia, specifically AD (HR = 1.28; 95%CI = [1.04–1.58]), but not DVC. No association was found for insomnia complaints and sleep quality taken as individual factors or combined with EDS on the risk of dementia. No association was found between β-amyloid, sleep complaints, and incident dementia.

Conclusions

The results suggest a deleterious role of EDS and hypnotics on dementia. Further studies are required to elucidate the mechanisms involved in these associations and whether its management can prevent the risk of dementia.

Relationship between sleep disorders and the prognosis of neurological function after stroke

Objective

This study aims to investigate the effects of sleep disorders on the prognosis of neurological function after stroke and other factors affecting the prognosis after stroke.

Method

We designed a cohort study. A total of 1,542 patients with their first stroke were hospitalized in the department of neurology of Tianjin Huanhu Hospital from 2015.6.1 to 2016.12.31. We recorded the personal histories of patients. The MMSE (mini-mental state examination), MoCA (Montreal Cognitive Assessment), HAMD (Hamilton Depression Scale), National Institutes of Health Stroke Scale (NIHSS) score, mRS (Modified Rankin Scale), BI (Barthel Index), PSQI (Pittsburgh Sleep Quality Index), ESS (Epworth Sleepiness Scale), Berlin questionnaire, and nocturnal TST (Total sleep time) were assessed before discharge, 3 months, 6 months, and 4 years (2019–2020) after stroke.

Result

Low sleep quality (OR 2.019, 95%CI 1.199–3.398, p = 0.008), nocturnal TST (&lt;7 h) (OR 4.060, 95%CI 1.494–11.034, p = 0.006), nocturnal TST (&gt;8 h) (OR 5.928, 95% CI 2.134–16.464, p = 0.001) were risk factors for poor neurological function recovery at 3 months after stroke. Nocturnal TST (&lt;7 h) (OR 13.042, 95%-CI 2.576–66.027, p = 0.002) and nocturnal TST (&gt;8 h) (OR 11.559, 95%-CI 2.108–63.390, p = 0.005) were risk factors for poor neurological function at 6 months after stroke. Nocturnal TST (&lt;7 h) (OR 2.668, 95% CI 1.250–5.698, p = 0.011) and nocturnal TST (&gt;8 h) (OR 2.516, 95% CI 1.080–5.861, p = 0.033) were risk factors for poor neurological function at 4 years after stroke. High risk of OSA (HR 1.582, 95%CI 1.244–2.012, p &lt; 0.001) was a risk factor for all-cause death in patients followed up for 4 years after stroke.

Conclusion

Low sleep quality is associated with short-term poor neurological function after stroke. Unusual nocturnal TST (long or short) is associated with short-term or long-term poor neurological function after stroke. A high risk of OSA is associated with a higher risk of all-cause death after stroke.

Self-reported sleepiness associates with greater brain and cortical volume and lower prevalence of ischemic covert brain infarcts in a community sample

STUDY OBJECTIVES

We evaluated if self-reported sleepiness was associated with neuroimaging markers of brain aging and ischemic damage in a large community-based sample.

METHODS

Participants from the Framingham Heart Study Offspring cohort (n = 468, 62.5 ± 8.7 years old, 49.6%M) free of dementia, stroke, and neurological diseases, completed sleep questionnaires and polysomnography followed by magnetic resonance imaging (MRI), 3 years later on average. We used linear and logistic regression models to evaluate the associations between Epworth Sleepiness Scale (ESS) scores and total brain, cortical and subcortical gray matter, and white matter hyperintensities volumes, and the presence of covert brain infarcts.

RESULTS

Higher sleepiness scores were associated with larger total brain volume, greater cortical gray matter volume, and a lower prevalence of covert brain infarcts, even when adjusting for a large array of potential confounders, including demographics, sleep profiles and disorders, organic health diseases, and proxies for daytime cognitive and physical activities. Interactions indicated that more sleepiness was associated with larger cortical gray matter volume in men only and in APOE ε4 noncarriers, whereas a trend for smaller cortical gray matter volume was observed in carriers. In longitudinal analyses, those with stable excessive daytime sleepiness over time had greater total brain and cortical gray matter volumes, whereas baseline sleepiness scores were not associated with subsequent atrophy or cognitive decline.

CONCLUSION

Our findings suggest that sleepiness is not necessarily a marker of poor brain health when not explained by diseases or sleep debt and sleep disorders. Rather, sleepiness could be a marker of preserved sleep-regulatory processes and brain health in some cases.

Understanding and approaching excessive daytime sleepiness

Excessive daytime sleepiness (EDS) is a public health issue. However, it remains largely undervalued, scarcely diagnosed, and poorly supported. Variations in the definition of EDS and limitations in clinical assessment lead to difficulties in its epidemiological study, but the relevance of this symptom from a socioeconomic perspective is inarguable. EDS might be a consequence of several behavioural issues leading to insufficient or disrupted sleep, as well as a consequence of sleep disorders including sleep apnoea syndrome, circadian disorders, central hypersomnolence disorders (narcolepsy and idiopathic hypersomnia), other medical or psychiatric conditions, or medications. Furthermore, EDS can have implications for health as it is thought to act as a risk factor for other conditions, such as cardiovascular and neurodegenerative disorders. Because of the heterogeneous causes of EDS and the complexity of its pathophysiology, management will largely depend on the cause, with the final aim of making treatment specific to the individual using precision medicine and personalised medicine.

Sleep in Normal Aging

Sleep is a key determinant of healthy and cognitive aging. Sleep patterns change with aging, independent of other factors, and include advanced sleep timing, shortened nocturnal sleep duration, increased frequency of daytime naps, increased number of nocturnal awakenings and time spent awake during the night, and decreased slow-wave sleep. The sleep-related hormone secretion changes with aging. Most changes seem to occur between young and middle adulthood; sleep parameters remain largely unchanged among healthy older adults. The circadian system and sleep homeostatic mechanisms become less robust with normal aging. The causes of sleep disturbances in older adults are multifactorial.

Self-Reported Sleep Characteristics Associated with Cardiovascular Disease Among Older Adults Living in Rural Eastern China: A Population-Based Study

Purpose

To investigate the cross-sectional associations of self-reported sleep characteristics with cardiovascular diseases (CVDs) and cardiovascular multimorbidity in older adults living in rural Eastern China.

Patients and Methods

This population-based study included 4618 participants (age ≥65 years; 56.5% women) living in rural Eastern China. In March–September 2018, data were collected through interviews, clinical examinations, neuropsychological testing, and laboratory tests. Sleep parameters were assessed using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Score, and Berlin questionnaire. Coronary heart disease (CHD), heart failure (HF), and stroke were defined according to in-person interviews, clinical and neurological examinations, and electrocardiogram examination. Data were analyzed using logistic regression and restricted cubic spline regression.

Results

CHD was diagnosed in 991 participants, HF in 135 participants, and stroke in 696 participants. The multivariable-adjusted odds ratio (OR) of CHD was 1.27 (95% CI, 1.09–1.49) for sleep duration ≤6 hours/night (vs >6–8 hours/night), 1.40 (1.20–1.62) for poor sleep quality, and 1.22 (1.04–1.43) for high risk for obstructive sleep apnea (OSA). The OR of HF was 2.16 (1.38–3.39) for sleep duration >8 hours/night, and 1.76 (1.22–2.54) for high risk for OSA. In addition, the OR of stroke was 1.23 (1.04–1.46) for poor sleep quality, 1.32 (1.01–1.72) for excessive daytime sleepiness, and 1.42 (1.19–1.70) for high risk for OSA. The associations of poor sleep with cardiovascular multimorbidity (≥2 CVDs) were stronger than that of sleep problems with a single CVD.

Conclusion

Extreme sleep duration, high risk for OSA, and other sleep problems were associated with CVDs, especially cardiovascular multimorbidity.

Prognostic Impact of Sleep Patterns and Related-Drugs in Patients with Heart Failure

Sleep disturbances are frequent among patients with heart failure (HF). We hypothesized that self-reported sleep disturbances are associated with a poor prognosis in patients with HF. A longitudinal study of 119 patients with HF was carried out to assess the association between sleep disturbances and the occurrence of major cardiovascular events (MACE). All patients with HF completed self-administered questionnaires on sleepiness, fatigue, insomnia, quality of sleep, sleep patterns, anxiety and depressive symptoms, and central nervous system (CNS) drugs intake. Patients were followed for a median of 888 days. Cox models were used to estimate the risk of MACE associated with baseline sleep characteristics. After adjustment for age, the risk of a future MACE increased with CNS drugs intake, sleep quality and insomnia scores as well with increased sleep latency, decreased sleep efficiency and total sleep time. However, after adjustment for left ventricular ejection fraction and hypercholesterolemia the HR failed to be significant except for CNS drugs and total sleep time. CNS drugs intake and decreased total sleep time were independently associated with an increased risk of MACE in patients with HF. Routine assessment of self-reported sleep disturbances should be considered to prevent the natural progression of HF.

Daytime sleepiness and risk of stroke: A Mendelian randomization analysis

OBJECTIVE

Daytime sleepiness is known to be related to stroke, but whether daytime sleepiness is a risk factor for stroke remains unclear. We conducted a two-sample Mendelian randomization study to assess the relationship between daytime sleepiness and stroke, ischemic stroke (IS) and IS subtypes.

METHODS

Thirty-six single-nucleotide polymorphisms (SNPs) associated with daytime sleepiness were selected as instrumental variables, which were identified from a recent genome-wide association study(N = 452,071). Summary statistics of the SNPs on stroke, IS and IS subtypes were derived from the MEGASTROKE consortium with 40,585 stroke cases and 406,111 controls.

RESULTS

We found that daytime sleepiness was associated with large artery stroke (OR, 6.75; 95%CI, 1.49-30.57; p = 0.013), but not with all stroke (OR, 1.29; 95%CI, 0.81-2.05; p = 0.282), all ischemic stroke(OR, 1.46; 95%CI, 0.90-2.39; p = 0.136), cardioembolic stroke(OR, 1.0; 95%CI, 0.39-2.64; p = 0.984), or small artery stroke(OR, 1.52; 95%CI, 0.46-5.05; p = 0.485).

CONCLUSION

Our findings indicated that daytime sleepiness is causally associated with an increased risk of large artery stroke. Further studies are necessary to verify our results and explain the physiological mechanisms.

Associations Between Sleep Quality and Health Span: A Prospective Cohort Study Based on 328,850 UK Biobank Participants

OBJECTIVE

To examine the associations between sleep quality and health span using a prospective cohort design based on the UK Biobank (UKB).

MATERIALS AND METHODS

This longitudinal cohort study enrolled 328,850 participants aged between 37 and 73 years from UKB to examine the associations between sleep quality and risk of terminated health span. End of health span was defined by eight events strongly associated with longevity (cancer, death, congestive heart failure, myocardial infarction, chronic obstructive pulmonary disease, stroke, dementia, and diabetes), and a sleep score was generated according to five sleep behavioral factors (sleep duration, chronotype, sleeplessness, daytime sleepiness, and snoring) to characterize sleep quality. The hazard ratio (HR) and 95% confidence intervals (CIs) were calculated by multivariate-adjusted Cox proportional hazards model. Moreover, we calculated population attributable risk percentage (PAR%) to reflect the public health significance of healthy sleep quality.

RESULTS

Compared with poor sleep quality, participants with healthy sleep quality had a 15% (HR: 0.85, 95% CI: 0.81-0.88) reduced risk of terminated health span, and those of less-healthy sleep quality had a 12% (HR: 0.88, 95% CI: 0.85-0.92) reduced risk. Linear trend results indicated that the risk of terminated health span decreased by 4% for every additional sleep score. Nearly 15% health span termination events in this cohort would have been prevented if a healthy sleep behavior pattern was adhered to (PAR%: 15.30, 95% CI: 12.58-17.93).

CONCLUSION

Healthy sleep quality was associated with a reduced risk of premature end of health span, suggesting healthy sleep behavior may extend health span. However, further studies are suggested for confirmation of causality and potential mechanism.

Investigation of the relationships between sleep behaviors and risk of healthspan termination: a prospective cohort study based on 323,373 UK-Biobank participants

OBJECTIVES

To examine the associations between four sleep behaviors and the risk of healthspan termination.

METHODS

This study included 323,373 participants, free of terminated healthspan at baseline, from the UK-Biobank (UKB). We applied multivariable-adjusted Cox regression models to estimate the risk of terminated healthspan based on four sleep behaviors (insomnia/sleeplessness, napping, daytime sleepiness, and difficulty getting up from bed), which were self-reported and measured on Likert scales from "usually" to "never/rarely" experiences. In this study, healthspan was defined based on eight events that are strongly associated with longevity (congestive heart failure, myocardial infarction, chronic obstructive pulmonary disease, stroke, dementia, diabetes, cancer, and death).

RESULTS

Participants who reported the following unhealthy sleep behaviors had a significantly higher risk of terminated healthspan: "usually experience sleeplessness/insomnia" (HR = 1.05, 95% CI: 1.03-1.07; P < 0.001); "usually nap" (HR = 1.22, 95% CI: 1.18-1.26; P < 0.01); "excessive daytime sleepiness" (HR = 1.25, 95% CI: 1.19-1.32; P < 0.001); and "difficult getting up from bed" (HR = 1.08, 95% CI: 1.05-1.10; P < 0.001). The corresponding population attributable risk percentage (PAR%) indicated that about 7% of healthspan termination in this cohort would have been eliminated if all participants had healthy sleep behaviors.

CONCLUSION

Participants who reported "usually experience sleeplessness/insomnia," "usually nap," "excessive daytime sleepiness," and "difficult getting up from bed" had increased risk of shortened healthspan. Therefore, adherence to healthy sleep behavior is significant for the extension of healthspan.

Cardiovascular disorders in narcolepsy: Review of associations and determinants

Narcolepsy type 1 (NT1) is a lifelong disorder of sleep-wake dysregulation defined by clinical symptoms, neurophysiological findings, and low hypocretin levels. Besides a role in sleep, hypocretins are also involved in regulation of heart rate and blood pressure. This literature review examines data on the autonomic effects of hypocretin deficiency and evidence about how narcolepsy is associated with multiple cardiovascular risk factors and comorbidities, including cardiovascular disease. An important impact in NT1 is lack of nocturnal blood pressure dipping, which has been associated with mortality in the general population. Hypertension is also prevalent in NT1. Furthermore, disrupted nighttime sleep and excessive daytime sleepiness, which are characteristic of narcolepsy, may increase cardiovascular risk. Patients with narcolepsy also often present with other comorbidities (eg, obesity, diabetes, depression, other sleep disorders) that may contribute to increased cardiovascular risk. Management of multimorbidity in patients with narcolepsy should include regular assessment of cardiovascular health (including ambulatory blood pressure monitoring), mitigation of cardiovascular risk factors (eg, cessation of smoking and other lifestyle changes, sleep hygiene, and pharmacotherapy), and prescription of a regimen of narcolepsy medications that balances symptomatic benefits with cardiovascular safety.

Excessive Daytime Sleepiness and Cardiovascular Mortality in US Adults: A NHANES 2005-2008 Follow-Up Study

PURPOSE

Excessive daytime sleepiness is highly prevalent and has been associated with increased risk of cardiovascular diseases, but evidence for its association with cardiovascular mortality is limited and inconsistent. We aimed to determine whether excessive daytime sleepiness is independently associated with cardiovascular mortality in general adult population.

PATIENTS AND METHODS

A prospective study of 10,330 adult participants (aged ≥20 years) from National Health and Nutrition Examination Survey (NHANES) 2005-2006 and 2007-2008 was followed up until December 31st, 2015. Excessive daytime sleepiness was defined as the self-reported feeling of being overly sleepy often or always during the day. Cox proportional hazard ratios (HRs) with 95% confidence interval (CI) were estimated to assess risk for cardiovascular mortality.

RESULTS

A total of 10,330 participants with mean age of 47.3 years (95% CI, 46.0 to 48.1) were included in this analysis. Approximately, 18.5% of US adults reported excessive daytime sleepiness. Over a mean follow-up of 8.3 years, 262 cardiovascular deaths occurred. Participants with excessive daytime sleepiness had 2.85-times greater risk (95% CI, 1.33-6.09) of cardiovascular death than those without daytime sleepiness in multivariable analysis corrected for sociodemographic factors, comorbidities and cardiovascular risk factors including depression. Further adjustment for self-reported sleep disorders and sleep duration only slightly attenuated this association (HR, 2.55; 95% CI, 1.23-5.27). No interactions between excessive daytime sleepiness and age, sex or cardiovascular disease at study entry were observed (all Ps>0.05).

CONCLUSION

Excessive daytime sleepiness is highly prevalent among US adults and is independently associated with an approximately two-and-a-half-fold increased risk of cardiovascular mortality in a large national sample. Screening for excessive daytime sleepiness may be a simple and cost-effective tool for identifying individuals at high risk of cardiovascular death.

Narrative review of sleep and stroke

Sleep disorders, such as sleep-disordered breathing (SDB), insomnia or restless legs syndrome (RLS), are common in the general population and after stroke. In some cases, sleep disturbances are pre-existing, but can also appear de novo as a direct consequence of brain damage or due to stroke-related complications. Furthermore, some sleep conditions may act as a risk factor of stroke. This review explores the available evidence of the two-way relationship between sleep and stroke. Cardiovascular physiological changes during sleep are described, as well as the evidence on the relationship between stroke and sleep duration, SDB, RLS, insomnia, excessive daytime sleepiness (EDS), and circadian rhythm alterations. Potential changes on sleep architecture, and the links that may exist between sleep and functional outcomes after stroke are also discussed. Importantly, sleep-related disturbances may be associated with worse stroke recovery outcomes and increased cerebrovascular morbidity. It is therefore relevant that the bidirectional association between stroke and sleep is taken into consideration by clinicians taking care of these patients. Future research may focus on this mutual relationship for a better understanding of the impact of stroke on sleep, the importance of sleep in stroke incidence and recovery, and have further evidence on treatment strategies that may improve functional outcome after stroke.

Sleep patterns, genetic susceptibility, and incident cardiovascular disease: a prospective study of 385 292 UK biobank participants

AIMS

To quantify the association of combined sleep behaviours and genetic susceptibility with the incidence of cardiovascular disease (CVD).

METHODS AND RESULTS

This study included 385 292 participants initially free of CVD from UK Biobank. We newly created a healthy sleep score according to five sleep factors and defined the low-risk groups as follows: early chronotype, sleep 7-8 h per day, never/rarely insomnia, no snoring, and no frequent excessive daytime sleepiness. Weighted genetic risk scores of coronary heart disease (CHD) or stroke were calculated. During a median of 8.5 years of follow-up, we documented 7280 incident CVD cases including 4667 CHD and 2650 stroke cases. Compared to those with a sleep score of 0-1, participants with a score of 5 had a 35% (19-48%), 34% (22-44%), and 34% (25-42%) reduced risk of CVD, CHD, and stroke, respectively. Nearly 10% of cardiovascular events in this cohort could be attributed to poor sleep pattern. Participants with poor sleep pattern and high genetic risk showed the highest risk of CHD and stroke.

CONCLUSION

In this large prospective study, a healthy sleep pattern was associated with reduced risks of CVD, CHD, and stroke among participants with low, intermediate, or high genetic risk.

The neurophysiological basis of excessive daytime sleepiness: suggestions of an altered state of consciousness

Excessive daytime sleepiness (EDS) is characterized by difficulty staying awake during daytime, though additional features may be present. EDS is a significant problem for clinical and non-clinical populations, being associated with a range of negative outcomes that also represent a burden for society. Extreme EDS is associated with sleep disorders, most notably the central hypersomnias such as narcolepsy, Kleine-Levin syndrome, and idiopathic hypersomnia (IH). Although investigation of these conditions indicates that EDS results from diminished sleep quality, the underlying cause for this impairment remains uncertain. One possibility could be that previous research has been too narrow in scope with insufficient attention paid to non-sleep-related aspects. Here, we offer a broader perspective in which findings concerning the impact of EDS on cortical functioning are interpreted in relation to current understanding about the neural basis of consciousness. Alterations in the spatial distribution of cortical activity, in particular reduced connectivity of frontal cortex, suggest that EDS is associated with an altered state of consciousness.

An Update on Dual Orexin Receptor Antagonists and Their Potential Role in Insomnia Therapeutics

STUDY OBJECTIVES

Current pharmacological options for the treatment of insomnia insufficiently meet the needs of all insomnia patients. Approved treatments are not consistently effective in improving sleep onset and sleep maintenance, while also having complicated safety profiles. These limitations highlight the unmet need for additional medications and treatment strategies. Initial research suggests that the dual orexin receptor antagonists (DORAs) may offer an additional pharmaceutical option to treat insomnia in some patients.

METHODS

We reviewed the existing literature on dual orexin receptor antagonists in PubMed databases using the search terms "orexin receptor antagonist," "almorexant" "filorexant," "lembroexant" and "suvorexant"; searches were limited to English language primary research articles, clinical trials, and reviews.

RESULTS

Targeting the orexin receptor system for treatment of insomnia offers an additional and alternative pharmacological approach to more common gamma aminobutyric acid agonist sedative hypnotic treatment. Effectiveness is not well established in the current literature; however, the literature does suggest efficacy. Preclinical reports also suggest the potential for treatment in individuals with comorbid Alzheimer disease and insomnia.

CONCLUSIONS

DORAs offer an additional treatment option for insomnia. More clinical trials are needed to robustly evaluate their safety and effectiveness in several subclasses of individuals with insomnia. Given the published literature, head-to-head comparisons to existing treatment for insomnia are warranted.

Sleep in Normal Aging

Sleep patterns change with aging, independent of other factors, and include advanced sleep timing, shortened nocturnal sleep duration, increased frequency of daytime naps, increased number of nocturnal awakenings and time spent awake during the night, and decreased slow wave sleep. Most of these changes seem to occur between young and middle adulthood; sleep parameters remain largely unchanged among healthy older adults. The circadian system and sleep homeostatic mechanisms become less robust with normal aging. The amount and pattern of sleep-related hormone secretion change as well. The causes of sleep disturbances in older adults are multifactorial.

Joint effects of OSA and self-reported sleepiness on incident CHD and stroke

BACKGROUND

Although excessive daytime sleepiness (EDS) is a common symptom of obstructive sleep apnea (OSA), and both EDS and OSA have separately been associated with increased risk of cardiovascular disease (CVD), their joint association with CVD risk is unknown.

METHODS

Among 3874 Sleep Heart Health Study (SHHS) participants without prevalent CVD, moderate to severe OSA was defined by an apnea hypopnea index (AHI) ≥ 15 on an in-home polysomnography. EDS was defined as an Epworth Sleepiness Scale score ≥11. Incident CVD events included total CVD events (coronary heart disease (CHD) and stroke), as well as CHD and stroke separately. Cox proportional hazards models adjusted for age, sex, alcohol, smoking, and body mass index.

RESULTS

Compared to those with AHI <15, the hazard ratios (95% CI) for the association of moderate-severe OSA (AHI ≥15) were as follows: CVD 1.06 (0.85-1.33); CHD 1.08 (0.85-1.33); and stroke 1.18 (0.75-1.84). Weak associations between EDS and CVD risk = [1.22 (1.01-1.47)] and CHD risk [1.25 (1.02-1.53)] were present, however there were none for stroke risk [1.10 (0.75-1.63)]. When jointly modeled, both AHI ≥15 and EDS (compared with having AHI <15 and no EDS) was associated with HRs of 1.26 (0.91-1.73) for CVD, 1.24 (0.87-1.75) for CHD and 1.49 (0.78-2.86) for stroke. There were no statistically significant interactions between daytime sleepiness and OSA on the multiplicative or additive scales.

CONCLUSIONS

Having both EDS and moderate-severe OSA was not associated with an increased risk of CVD in the SHHS data.

The gait speed advantage of taller stature is lost with age

Taller individuals walk faster but it is unknown whether this advantage persists at older ages. We examined the cross-sectional/longitudinal associations of height with gait speed (GS) in participants from the Dijon-Three-City cohort study (France) over 11 years. In 4011 participants (65–85 y), we measured usual/fast GS (6 m) up to five times. We examined whether the baseline height-GS association varied with age using linear regression, and whether height influenced GS change using linear mixed models. Taller participants 65 y at baseline walked faster than shorter ones (fast GS difference between top/bottom height quartiles, 0.100 m/s, P < 0.001); this association weakened with age (P-interaction = 0.02), with a 0.012 m/s (P = 0.57) difference at 80 y. Ten-year fast GS decline was 51% greater (P < 0.001) in younger participants in the top height quartile (−0.183 m/s) compared to those in the bottom quartile (−0.121 m/s), leading the GS difference between the two groups to be attenuated by 50% over the follow-up. The height-related difference in fast GS decline was not explained by time-dependent comorbidities or height shrinkage. Analyses for usual GS yielded consistent findings. The height-GS relation is more complex than previously thought, as the height related advantage in GS disappears as persons grow older due to faster decline in taller compared to shorter persons.

Excessive Sleepiness and Longer Nighttime in Bed Increase the Risk of Cognitive Decline in Frail Elderly Subjects: The MAPT-Sleep Study

Objective: To identify self-reported sleep-wake disturbances that increase the risk of cognitive decline over 1-year follow-up in frail participants.

Background: Risk factors for cognitive impairment need to be better identified especially at earliest stages of the pathogenesis. Sleep-wake disturbances may be critical factors to consider and were thus being assessed in this at-risk population for cognitive decline.

Methods: Frail elderly participants aged ≥70 years were selected from a subsample of the Multi-domain Alzheimer Preventive Trial (MAPT) for a sleep assessment (MAPT-sleep study) at 18-month follow-up (M18). Sleep-wake disturbances were evaluated using a clinical interview (duration of daytime and nighttime sleep, time in bed, number of naps, and presence of clinically-defined sleep disorders) and numerous validated questionnaires [Epworth Sleepiness Scale for excessive daytime sleepiness (EDS), Insomnia Severity Scale and Berlin Questionnaire]. Cognitive decline was defined as a difference between the MMSE and cognitive composite scores at M24 and M36 that was ranked in the lowest decile. Multivariate logistic regression models adjusted for several potential confounding factors were performed.

Results: Among the 479 frail participants, 63 developed MMSE-cognitive decline and 50 cognitive composite score decrease between M24 and M36. Subjects with EDS had an increased risk of MMSE decline (OR = 2.46; 95% CI [1.28; 4.71], p = 0.007). A longer time spent in bed during night was associated with cognitive composite score decline (OR = 1.32 [1.03; 1.71], p = 0.03). These associations persisted when controlling for potential confounders. Patients with MMSE score decline and EDS had more naps, clinically-defined REM-sleep Behavior Disorder, fatigue and insomnia symptoms, while patients with cognitive composite score decline with longer time in bed had increased 24-h total sleep time duration but with higher wake time after onset.

Conclusions: The risk of cognitive decline is higher in frailty subjects with EDS and longer nighttime in bed. Early detection of sleep-wake disturbances might help identifying frail subjects at risk of cognitive decline to further propose sleep health strategies to prevent cognitive impairment.

http://www.clinicaltrials.gov NCT00672685; Date of registration May, 2nd 2008.

Self-reported sleep duration and napping, cardiac risk factors and markers of subclinical vascular disease: cross-sectional study in older men

STUDYOBJECTIVES

Daytime sleep has been associated with increased risk of cardiovascular disease and heart failure (HF), but the mechanisms remain unclear. We have investigated the association between daytime and night-time sleep patterns and cardiovascular risk markers in older adults including cardiac markers and subclinical markers of atherosclerosis (arterial stiffness and carotid intima-media thickness (CIMT)).

METHODS

Cross-sectional study of 1722 surviving men aged 71-92 examined in 2010-2012 across 24 British towns from a prospective study initiated in 1978-1980. Participants completed a questionnaire and were invited for a physical examination. Men with a history of heart attack or HF (n=251) were excluded from the analysis.

RESULTS

Self-reported daytime sleep duration was associated with higher fasting glucose and insulin levels (p=0.02 and p=0.01, respectively) even after adjustment for age, body mass index, physical activity and social class. Compared with those with no daytime sleep, men with daytime sleep >1 hour, defined as excessive daytime sleepiness (EDS), had a higher risk of raised N-terminal pro-brain natriuretic peptide of ≥400 pg/mL, the diagnostic threshold for HF (OR (95% CI)=1.88 (1.15 to 3.1)), higher mean troponin, reduced lung function (forced expiratory volume in 1 s) and elevated von Willebrand factor, a marker of endothelial dysfunction. However, EDS was unrelated to CIMT and arterial stiffness. By contrast, night-time sleep was only associated with HbA1c (short or long sleep) and arterial stiffness (short sleep).

CONCLUSIONS

Daytime sleep duration of >1 hour may be an early indicator of HF.

French consensus. Hypersomnolence: Evaluation and diagnosis

Sleepiness is one of the most frequently reported complaints in adults and children during specialised sleep consultations. It is responsible for an alteration that can be severe in quality of life, a lowering of academic or professional performance, and domestic or work accidents. Hypersomnolence is the first cause of road accidents on the highway, responsible for a third of fatal accidents. Furthermore its presence is associated with an increased risk of morbi-mortality related to cardiovascular and neurodegenerative pathologies. Hence, its represents a real public health issue. Recent revisions in international classifications have clarified confusing terminology, and the complaint of hypersomnia has now been replaced by the terms hypersomnolence or excessive sleepiness. It is clinically defined as an excessive quantity of sleep over 24hours, and/or by an alteration in the quality of arousal defined as incapacity to maintain a satisfactory level of vigilance during the day or in the morning on awakening (defined as sleep inertia). The evaluation of sleepiness requires a rigorous clinical approach, completed by subjective and objective measurements. The Epworth Sleep Scale, Multiple Sleep Latency Tests and the Maintenance of Wakefulness Test are the most studied and used in clinical practice. However, to date, no gold standard measurement of excessive sleepiness exists, and there are no quantifiable biological markers. It is therefore important to optimise our evaluation tools, improve our pathophysiological understanding of sleepiness, and define genetic and environmental risk factors.

Wake-up stroke: Clinical characteristics, sedentary lifestyle, and daytime sleepiness

Summary Objective: Wake-up stroke (WUS) is defined when the exact time of the beginning of the symptoms cannot be determined, for the deficits are perceived upon awakening. Sleep alterations are important risk factors for stroke and cardiovascular diseases. This study evaluates the characteristics of patients with and without WUS, the presence of daytime sleepiness, and associated risk factors. Method: Patients with ischemic stroke were investigated about the presence of WUS. Clinical and demographic characteristics were evaluated. Stroke severity was studied by the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS), and daytime sleepiness severity was studied by the Epworth Sleepiness Scale (ESS). Results: Seventy patients (57.1% men) aged from 32 to 80 years (58.5±13.3) were studied. WUS was observed in 24.3%. Arterial hypertension (67.1%), type 2 diabetes (27.1%), and hyperlipidemia (22.8%) were frequent. Type 2 diabetes and sedentary lifestyle were more common in patients with WUS (p<0.05). Overall, mild, moderate or very few symptoms of stroke (NIHSS<5) were predominant (62.3%). Among all cases, 20% had excessive daytime sleepiness (ESS>10). No differences were found between patients with and without WUS as regards stroke severity or excessive daytime sleepiness. Patients with excessive daytime sleepiness were younger and had more sedentary lifestyle (p<0.05). Individuals with previous history of heavy drinking had more daytime sleepiness (p=0.03). Conclusion: Wake-up stroke occurs in approximately 25% of stroke cases. In this study, patients with WUS had more diabetes and sedentary lifestyle. Daytime sleepiness is frequent and is associated with sedentary lifestyle and heavy drinking.

Sleep quality and adverse outcomes for patients with acute myocardial infarction

AIMS AND OBJECTIVES

This study aimed to analyse the relationship between the worsening of clinical outcomes (cardiovascular death, recurrent cardiovascular ischaemic events and stroke) and sleep quality, daytime sleepiness and risk for obstructive sleep apnoea syndrome in patients admitted to cardiac care units due to an acute myocardial infarction.

BACKGROUND

There is evidence that sleep disorders can contribute to the worsening of cardiovascular diseases.

DESIGN

This is a descriptive study with follow-up.

METHODS

Data collection was conducted in a large university hospital in Brazil from October 2013 to March 2014. Patients admitted with acute myocardial infarction provided data about sleep quality, daytime sleepiness and risk factors for obstructive sleep apnoea syndrome by answering specific questionnaires. Clinical data were obtained from medical charts. Data were analysed with descriptive statistics and multiple logistic regression models.

RESULTS

The worsening of clinical outcome occurred in 12·4% of patients and was independently associated to poor sleep quality.

CONCLUSION

Poor sleep quality, excessive daytime sleepiness and high risk for obstructive sleep apnoea syndrome were frequent in hospitalised patients with acute myocardial infarction and affect negatively the process of recovery.

RELEVANCE TO CLINICAL PRACTICE

It is important to evaluate sleep quality and sleep disorders, aiming at preventing and reducing unfavourable outcomes of cardiovascular disease, particularly for acute myocardial infarction patients.

Role of sleep-disordered breathing and sleep-wake disturbances for stroke and stroke recovery

Background:

Sleep-disordered breathing (SDB) and sleep-wake disturbances (SWD) are highly prevalent in stroke patients. Recent studies suggest that they represent both a risk factor and a consequence of stroke and affect stroke recovery, outcome, and recurrence.

Methods:

Review of literature.

Results:

Several studies have proven SDB to represent an independent risk factor for stroke. Sleep studies in TIA and stroke patients are recommended in view of the very high prevalence (>50%) of SDB (Class IIb, level of evidence B). Treatment of obstructive SDB with continuous positive airway pressure is recommended given the strength of the increasing evidence in support of a positive effect on outcome (Class IIb, level of evidence B). Oxygen, biphasic positive airway pressure, and adaptive servoventilation may be considered in patients with central SDB. Recently, both reduced and increased sleep duration, as well as hypersomnia, insomnia, and restless legs syndrome (RLS), were also suggested to increase stroke risk. Mainly experimental studies found that SWD may in addition impair neuroplasticity processes and functional stroke recovery. Treatment of SWD with hypnotics and sedative antidepressants (insomnia), activating antidepressants or stimulants (hypersomnia), dopaminergic drugs (RLS), and clonazepam (parasomnias) are based on single case observations and should be used with caution.

Conclusions:

SDB and SWD increase the risk of stroke in the general population and affect short- and long-term stroke recovery and outcome. Current knowledge supports the systematic implementation of clinical procedures for the diagnosis and treatment of poststroke SDB and SWD on stroke units.

Self-Reported Sleep Duration, Napping, and Incident Heart Failure: Prospective Associations in the British Regional Heart Study

Objectives

To examine the associations between self‐reported nighttime sleep duration and daytime sleep and incident heart failure (HF) in men with and without preexisting cardiovascular disease (CVD).

Design

Population‐based prospective study.

Setting

General practices in 24 British towns.

Participants

Men aged 60–79 without prevalent HF followed for 9 years (N = 3,723).

Measurements

Information on incident HF cases was obtained from primary care records. Assessment of sleep was based on self‐reported sleep duration at night and daytime napping.

Results

Self‐reported short nighttime sleep duration and daytime sleep of longer than 1 hour were associated with preexisting CVD, breathlessness, depression, poor health, physical inactivity, and manual social class. In all men, self‐reported daytime sleep of longer than 1 hour duration was associated with significantly greater risk of HF after adjustment for potential confounders (adjusted hazard ratio (aHR) = 1.69, 95% CI = 1.06–2.71) than in those who reported no daytime napping. Self‐reported nighttime sleep duration was not associated with HF risk except in men with preexisting CVD (<6 hours: aHR = 2.91, 95% CI = 1.31–6.45; 6 hours: aHR = 1.89, 95% CI = 0.89–4.03; 8 hours: aHR = 1.29, 95% CI = 0.61–2.71; ≥9 hours: aHR = 1.80, 905% CI = 0.71–4.61 vs nighttime sleep of 7 hours). Snoring was not associated with HF risk.

Conclusion

Self‐reported daytime napping of longer than 1 hour is associated with greater risk of HF in older men. Self‐reported short sleep (<6 hours) in men with CVD is associated with particularly high risk of developing HF.

Habitual Sleep Duration, Unmet Sleep Need, and Excessive Daytime Sleepiness in Korean Adults

Background and Purpose

Sleep need differs between individuals, and so the same duration of sleep will lead to sleep insufficiency in some individuals but not others. The aim of this study was to determine the separate and combined associations of both sleep duration and unmet sleep need with excessive daytime sleepiness (EDS) in Korean adults.

Methods

The participants comprised 2,769 Korean adults aged 19 years or older. They completed questionnaires about their sleep habits over the previous month. The question regarding sleep need was "How much sleep do you need to be at your best during the day?" Unmet sleep need was calculated as sleep need minus habitual sleep duration. Participants with a score of >10 on the Epworth Sleepiness Scale were considered to have EDS.

Results

The overall prevalence of EDS was 11.9%. Approximately one-third of the participants (31.9%) reported not getting at least 7 hours of sleep. An unmet sleep need of >0 hours was present in 30.2% of the participants. An adjusted multivariate logistic regression analysis revealed a significant excess risk of EDS in the groups with unmet sleep needs of ≥2 hours [odds ratio (OR), 1.80; 95% confidence interval (CI), 1.27–2.54] and 0.01–2 hours (OR, 1.42; 95% CI, 1.02–1.98). However, habitual sleep duration was not significantly related to EDS.

Conclusions

EDS was found to be associated with unmet sleep need but not with habitual sleep duration when both factors were examined together. We suggest that individual unmet sleep need is more important than habitual sleep duration in terms of the relation to EDS.

Impact of sleep disturbances on kidney function decline in the elderly

While sleep disturbances are frequent in renal disease patients, no studies have examined prospectively the associations between sleep disturbances and kidney function decline in community-dwelling elderly subjects.

Glomerular filtration rates (eGFRs) were estimated at baseline and at 11-year follow-up. A glomerular filtration decline over the follow-up period was defined as a percentage decline greater than or equal to the cut-off value of the highest tertile of kidney function decline (22%) in 1105 subjects. Excessive daytime sleepiness (EDS) and insomnia complaints were self-rated at baseline. Restless legs syndrome (RLS) and its age at onset were assessed at study end-point. An ambulatory polysomnography recording was performed during the follow-up in 277 subjects. Apnoea-hypopnoea index (AHI), periodic limb movements during sleep (PLMS) and total sleep time were analysed.

An increased risk of eGFR decline was associated with EDS (OR 1.67, 95% CI 1.18–2.34) and RLS (OR 1.98, 95% CI 1.18–3.30) independently of potential confounders including cardiovascular risk factors. Among insomnia complaints, a borderline association with eGFR decline was found for early morning awakening only. High AHI (≥30 events·h−1) and short total sleep time (<6 h), but not PLMS were linked to eGFR decline in crude associations, but only AHI remained significantly associated after multi-adjustments.

EDS, RLS and AHI constitute independent risk factors for kidney glomerular function decline.

Sleep complaints and metabolic syndrome in an elderly population: the Three-City Study

OBJECTIVES

To assess whether sleep complaints (rather than clinically defined sleep disturbances) were associated with the metabolic syndrome (MetS) and each of its components in an elderly population.

METHODS

Cross-sectional analyses of data from the French Three City Study, a large multicenter cohort of elderly community-dwellers.

PARTICIPANTS

6,354 participants (56.4% women, median age 73; range: 65-97 years).

MEASUREMENTS

Frequency of insomnia complaints (difficulty in initiating sleep, difficulty in maintaining sleep [DMS], and early morning awakening) and excessive daytime sleepiness (EDS) were self-reported. MetS was assessed using National Cholesterol Education program Adult Treatment Panel III criteria.

RESULTS

A total of 977 participants had MetS. After adjustment for a large range of potential confounders, we report an association between the number of insomnia complaints and MetS. Among insomnia complaints only DMS was consistently associated with MetS (OR: 1.23, 95% CI: 1.06 to 1.43). Our results showed that EDS independently increased the risk of MetS (OR: 1.46, 95% CI: 1.18 to 1.81 for "frequently"; OR: 1.99, 95% CI: 1.49 to 1.67 for "often"). The EDS-MetS association was independent of past-history of cardiovascular disease, insomnia complaints, and obesity and loud snoring.

CONCLUSION

We report significant independent associations between frequent sleep complaints (EDS and to a lesser extent DMS) and MetS in the elderly with potential implications in terms of management and cardiovascular prevention in general geriatric practice. Prospective studies are required to clarify the direction of the association between sleep complaints and MetS.