The prevalence and clinical significance of sleep disorders in acute ischemic stroke patients—a questionnaire study

Sleep disorders as both risk factors for, and a consequence of, stroke: A narrative review

BACKGROUND AND PURPOSE

Sleep disorders are increasingly implicated as risk factors for stroke, as well as a determinant of stroke outcome. They can also occur secondary to the stroke itself. In this review, we describe the variety of different sleep disorders associated with stroke and analyze their effect on stroke risk and outcome.

METHODS

A search term-based literature review ("sleep," "insomnia," "narcolepsy," "restless legs syndrome," "periodic limb movements during sleep," "excessive daytime sleepiness" AND "stroke" OR "cerebrovascular" in PubMed; "stroke" and "sleep" in ClinicalTrials.gov) was performed. English articles from 1990 to March 2023 were considered.

RESULTS

Increasing evidence suggests that sleep disorders are risk factors for stroke. In addition, sleep disturbance has been reported in half of all stroke sufferers; specifically, an increase is not only sleep-related breathing disorders but also periodic limb movements during sleep, narcolepsy, rapid eye movement (REM) sleep behavior disorder, insomnia, sleep duration, and circadian rhythm sleep-wake disorders. Poststroke sleep disturbance has been associated with worse outcome.

CONCLUSION

Sleep disorders are risk factors for stroke and associated with worse stroke outcome. They are also a common consequence of stroke. Recent guidelines suggest screening for sleep disorders after stroke. It is possible that treatment of sleep disorders could both reduce stroke risk and improve stroke outcome, although further data from clinical trials are required.

Development of insomnia in patients with stroke: A systematic review and meta-analysis

BACKGROUND AND AIM

Stroke is a serious threat to human life and health, and post-stroke insomnia is one of the common complications severely impairing patients' quality of life and delaying recovery. Early understanding of the relationship between stroke and post-stroke insomnia can provide clinical evidence for preventing and treating post-stroke insomnia. This study was to investigate the prevalence of insomnia in patients with stroke.

METHODS

The Web of Science, PubMed, Embase, and Cochrane Library databases were used to obtain the eligible studies until June 2023. The quality assessment was performed to extract valid data for meta-analysis. The prevalence rates were used a random-efect. I2 statistics were used to assess the heterogeneity of the studies.

RESULTS

Twenty-six studies met the inclusion criteria for meta-analysis, with 1,193,659 participants, of which 497,124 were patients with stroke.The meta-analysis indicated that 150,181 patients with stroke developed insomnia during follow-up [46.98%, 95% confidence interval (CI): 36.91-57.18] and 1806 patients with ischemic stroke (IS) or transient ischemic attack (TIA) developed insomnia (47.21%, 95% CI: 34.26-60.36). Notably, 41.51% of patients with the prevalence of nonclassified stroke developed insomnia (95% CI: 28.86-54.75). The incidence of insomnia was significantly higher in patients with acute strokes than in patients with nonacute strokes (59.16% vs 44.07%, P < 0.0001).Similarly, the incidence of insomnia was significantly higher in the patients with stroke at a mean age of ≥65 than patients with stroke at a mean age of <65 years (47.18% vs 40.50%, P < 0.05). Fifteen studies reported the follow-up time. The incidence of insomnia was significantly higher in the follow-up for ≥3 years than follow-up for <3 years (58.06% vs 43.83%, P < 0.05). Twenty-one studies used the Insomnia Assessment Diagnostic Tool, and the rate of insomnia in patients with stroke was 49.31% (95% CI: 38.59-60.06). Five studies used self-reporting, that the rate of insomnia in patients with stroke was 37.58% (95% CI: 13.44-65.63).

CONCLUSIONS

Stroke may be a predisposing factor for insomnia. Insomnia is more likely to occur in acute-phase stroke, and the prevalence of insomnia increases with patient age and follow-up time. Further, the rate of insomnia is higher in patients with stroke who use the Insomnia Assessment Diagnostic Tool.

Alleviating sleep disturbances and modulating neuronal activity after ischemia: Evidence for the benefits of zolpidem in stroke recovery

AIMS

Sleep disorders are prevalent among stroke survivors and impede stroke recovery, yet they are still insufficiently considered in the management of stroke patients, and the mechanisms by which they occur remain unclear. There is evidence that boosting phasic GABA signaling with zolpidem during the repair phase improves stroke recovery by enhancing neural plasticity; however, as a non-benzodiazepine hypnotic, the effects of zolpidem on post-stroke sleep disorders remain unclear.

METHOD

Transient ischemic stroke in male rats was induced with a 30-minute middle cerebral artery occlusion. Zolpidem or vehicle was intraperitoneally delivered once daily from 2 to 7 days after the stroke, and the electroencephalogram and electromyogram were recorded simultaneously. At 24 h after ischemia, c-Fos immunostaining was used to assess the effect of transient ischemic stroke and acute zolpidem treatment on neuronal activity.

RESULTS

In addition to the effects on reducing brain damage and mitigating behavioral deficits, repeated zolpidem treatment during the subacute phase of stroke quickly ameliorated circadian rhythm disruption, alleviated sleep fragmentation, and increased sleep depth in ischemic rats. Immunohistochemical staining showed that in contrast to robust activation in para-infarct and some remote areas by 24 h after the onset of focal ischemia, the activity of the ipsilateral suprachiasmatic nucleus, the biological rhythm center, was strongly suppressed. A single dose of zolpidem significantly upregulated c-Fos expression in the ipsilateral suprachiasmatic nucleus to levels comparable to the contralateral side.

CONCLUSION

Stroke leads to suprachiasmatic nucleus dysfunction. Zolpidem restores suprachiasmatic nucleus activity and effectively alleviates post-stroke sleep disturbances, indicating its potential to promote stroke recovery.

Increasing of Cortisol Level and Neutrophil-Lymphocyte-Ratio are Associated with Severity Level and Sleep Disturbances in Acute Ischemic Stroke

Background

Acute ischemic stroke can cause sleep disturbances. These complaints involve various factors, such as disturbances of the hormone cortisol and Neutrophil-Lymphocyte-Ratio (NLR) that can cause increasing severity levels in acute ischemic stroke patients. This study aimed to determine the relationship between cortisol levels and NLR with severity levels and sleep disturbances in acute ischemic stroke patients.

Methods

A cross-sectional analytic observational study was conducted on acute ischemic stroke patients during Agustus - December 2022. Examine cortisol levels using the ELISA method, NLR from blood test, asses severity levels using the National Institute of Health Stroke Scale (NIHSS), and The Pittsburgh Sleep Questionnaire Index (PSQI) is used as a measure for the initial screening of sleep disturbances-statistical analysis using Spearman correlation.

Results

Total study subjects were 48 patients, with the majority 62.5% women; the mean age of study subjects was above 60 years (56.3%), and the most common type of stroke was large artery atherosclerotic stroke (77.1%), the highest NIHSS score was in the moderate category (85.4%), the most common risk factor is hypertension (64.4%), and basal ganglia area is the most common ischemic stroke location (52.1%). There was a positive correlation between cortisol levels with NIHSS (r=0.874; p-value <0.001), NLR with sleep disturbances (r=0.829; p-value<0.001), NLR with NIHSS (r=0.893; p-value<0.001), and NIHSS with PSQI (r=0.836; p-value<0.001).

Conclusion

There were a positive correlation between cortisol level, NLR level, and NIHSS score with sleep quality disturbances based on PSQI in acute ischemic stroke patients.

Comparison of three measures for insomnia in ischemic stroke patients: Pittsburgh sleep quality index, insomnia severity index, and Athens insomnia scale

Objective

This study investigated the consistency and determined the optimal threshold values of three scales in the diagnosis of insomnia of ischemic stroke (IS) patients.

Methods

Participants in this study consisted of 569 acute IS patients. All 569 patients completed the assessment of the three insomnia scales. Insomnia of IS patients were assessed by Pittsburgh sleep quality index (PSQI), Insomnia Severity Index (ISI), and Athens insomnia scale (AIS). Also, basic patient information, neurological function, and activities of daily living were assessed. General information was compared between the insomnia group and the no-insomnia group. Cronbach's α coefficients, Cohen's Kappa consistency, Receiver operating characteristic (ROC) curve and DeLong's test analysis were used to analyze the reliability and diagnostic validity of PSQI, ISI, and AIS.

Results

The PSQI and ISI showed high reliability with Cronbach's α of 0.875 and 0.858, respectively, while the AIS had an α coefficient of 0.734, demonstrating acceptable reliability. The PSQI, ISI, and AIS showed outstanding diagnostic ability with an AUC of 0.960 (95% CI: 0.946, 0.974), 0.911 (95% CI: 0.882, 0.941), and 0.876 (95% CI:0.837, 0.916). The best diagnostic cutoffs for PSQI, ISI, and AIS are ≥9, ≥15, and ≥8.

Conclusion

Each of the three questionnaires has advantages and disadvantages when assessing insomnia. In the evaluation of insomnia in IS patients, the best questionnaire selection should be made according to the purpose of clinical evaluation and considering the sensitivity and specificity.

Sleep Quality and Cognitive Function after Stroke: The Mediating Roles of Depression and Anxiety Symptoms

This study examined the association between post-stroke cognitive function and sleep status at 30 days post-stroke and evaluated the role of anxiety and depression as potential mediators of that association. The participants in this study were 530 acute ischemic stroke (IS) patients. Sleep disturbance at 30 days post-stroke was assessed by the Pittsburgh Sleep Quality Index. Basic patient information, cognitive function, depression, and anxiety status were assessed before discharge from the hospital. Stratified linear regression analysis models were fit to examine the associations between post-stroke sleep quality and the influencing factors. A structural equation model was developed to evaluate the role of anxiety and depression as potential mediators of sleep quality and cognitive function. At 30 days post-stroke, 58.7% of IS patients had sleep disturbance. Women and older IS patients were more likely to suffer poorer sleep quality (p < 0.05). A stratified linear regression analysis showed that the inclusion of cognitive function variables and indicators of depression and anxiety were statistically significant in predicting improvement in the sleep disturbance of AIS patients. Cognitive function, depression, anxiety, and sleep status were selected to construct a structural equation model. The total effect of cognitive function on sleep status was -0.274, with a direct effect of -0.097 and an indirect effect (through depression) of -0.177. The total effect of anxiety on sleep status was 0.235, with a direct effect of 0.186 and an indirect effect (through depression) of 0.049. IS patients often experience poor sleep quality. Depression in IS patients mediates two pathways: the pathway through which cognitive function affects sleep quality and the pathway through which anxiety affects sleep quality.

Frequency and evolution of sleep-wake disturbances after ischemic stroke: A 2-year prospective study of 437 patients

OBJECTIVE

In the absence of systematic and longitudinal data, this study prospectively assessed both frequency and evolution of sleep-wake disturbances (SWD) after stroke.

METHODS

In 437 consecutively recruited patients with ischemic stroke or transient ischemic attack (TIA), stroke characteristics and outcome were assessed within the 1^st week and 3.2 ± 0.3 years (M±SD) after the acute event. SWD were assessed by interview and questionnaires at 1 and 3 months as well as 1 and 2 years after the acute event. Sleep disordered breathing (SDB) was assessed by respirography in the acute phase and repeated in one fifth of the participants 3 months and 1 year later.

RESULTS

Patients (63.8% male, 87% ischemic stroke and mean age 65.1 ± 13.0 years) presented with mean NIHSS-score of 3.5 ± 4.5 at admission. In the acute phase, respiratory event index was >15/h in 34% and >30/h in 15% of patients. Over the entire observation period, the frequencies of excessive daytime sleepiness (EDS), fatigue and insomnia varied between 10-14%, 22-28% and 20-28%, respectively. Mean insomnia and EDS scores decreased from acute to chronic stroke, whereas restless legs syndrome (RLS) percentages (6-9%) and mean fatigue scores remained similar. Mean self-reported sleep duration was enhanced at acute stroke (month 1: 07:54 ± 01:27h) and decreased at chronic stage (year 2: 07:43 ± 01:20h).

CONCLUSIONS

This study documents a high frequency of SDB, insomnia, fatigue and a prolonged sleep duration after stroke/TIA, which can persist for years. Considering the negative effects of SWD on physical, brain and mental health these data suggest the need for a systematic assessment and management of post-stroke SWD.

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.

Reduced serum vitamin D levels are associated with poor sleep quality in early stroke patients

Background

Poor sleep quality and vitamin D deficiency are common in stroke patients. Our aim was to evaluate the possible association between vitamin D and sleep quality in acute ischemic stroke (AIS) patients.

Methods

A total of 301 AIS patients were screened and completed 1-month follow-up. Serum 25-hydroxyvitamin D [25(OH)D] was used to assess the vitamin D status by a competitive protein-binding assay at baseline. All patients were divided into equal quartile according to the distribution of 25(OH)D. One month after stroke, sleep quality was evaluated by using Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaire; depression status was confirmed by 17-item Hamilton Depression Scale (HAMD).

Results

There were 89 (29.6%) AIS patients with poor sleep quality 1-month post-event. Within 24 h after admission, serum 25(OH)D levels were significantly lower in patients with poor sleep quality after stroke (P &lt; 0.001). In the results of multivariate-adjusted logistic regression analysis, the odds ratio (OR) of poor sleep quality was 6.199 (95% CI, 2.066–18.600) for the lowest quartile of 25(OH)D compared with the highest quartile. In patients without depression, reduced 25(OH)D were still significantly associated with poor sleep quality (OR = 8.174, 95% CI = 2.432–27.473). Furthermore, 25(OH)D and HAMD score were combined to enhance the diagnostic accuracy of poor sleep quality, with the area under the receiver operating characteristic curve of 0.775.

Conclusion

Reduced serum levels of vitamin D at admission were independently and significantly associated with poor sleep quality at 1 month after stroke. Our findings suggested the combination of vitamin D and depression status could provide important predictive information for post-stroke sleep quality.

Impact of Persistent Poor Sleep Quality on Post-Stroke Anxiety and Depression: A National Prospective Clinical Registry Study

PURPOSE

The impact of poor sleep quality after stroke, especially persistent poor sleep quality, on poststroke anxiety and depression is unclear. We seek to investigate the impact of baseline and persistent poor sleep quality on short-term poststroke anxiety and depression.

PATIENTS AND METHODS

Data were analyzed for 1619 patients with acute ischemic stroke from the Impairment of Cognition and Sleep after Acute Ischemic Stroke or Transient Ischemic Attack in Chinese Patients study (ICONS). The sleep quality was assessed at 2 weeks and 3 months using the Pittsburgh Sleep Quality Index scale (PSQI). Poor sleep quality was defined as a PSQI score of >5, and persistent poor sleep quality was defined as a PSQI score of >5 at each time point. Patients were divided into three groups according to the quality of sleep: good sleep quality, baseline poor sleep quality and persistent poor sleep quality. Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 scale (GAD-7), and Modified Rankin Scale (mRS) at 3 months after stroke were taken as the study outcomes.

RESULTS

Persistent poor sleep quality was present in 70.2% of patients after stroke. Compared to those with good sleep quality, patients with baseline poor sleep quality did not show significant differences in disability, anxiety and depression. However, patients with persistent poor sleep were at increased risk of depression (odds ratio, OR 3.04, 95% confidence interval, CI 1.66-5.57, P < 0.01) and anxiety (OR 3.20, 95% CI 1.42-7.19, P < 0.01) at 3 months after stroke. Persistent poor sleep quality was not identified as a risk factor for functional disability at 3 months.

CONCLUSION

Patients with persistent poor sleep quality are at added risks for depression and anxiety after stroke.

Melatonin supplementation in the subacute phase after ischemia alleviates postischemic sleep disturbances in rats

BACKGROUND

Sleep disorders are highly prevalent among stroke survivors and impede stroke recovery. It is well established that melatonin has neuroprotective effects in animal models of ischemic stroke. However, as a modulator of endogenous physiological circadian rhythms, the effects of melatonin on poststroke sleep disorders remain unclear. In the present study, we investigated how melatonin delivered intraperitoneally once daily in the subacute phase after stroke onset, influencing neuronal survival, motor recovery, and sleep-wake profiles in rats.

METHODS

Transient ischemic stroke in male Sprague-Dawley rats was induced with 30 min occlusion of the middle cerebral artery. Melatonin or vehicle was delivered intraperitoneally once daily in the subacute phase, from 2 to 7 days after stroke. Electroencephalogram and electromyogram recordings were obtained simultaneously.

RESULTS

Compared to the effects observed in the vehicle-treated ischemic group, after 6 daily consecutive treatment of melatonin at 10 mg/kg starting at ischemic/reperfusion day 2, the infarct volume was significantly decreased (from 39.6 to 26.2%), and the degeneration of axons in the ipsilateral striatum and the contralateral corpus callosum were significantly alleviated. Sensorimotor performances were obviously improved as evidenced by significant increases in the latency to falling off the wire and in the use of the impaired forelimb. In addition to those predictable results of reducing brain tissue damage and mitigating behavioral deficits, repeated melatonin treatment during the subacute phase of stroke also alleviated sleep fragmentation through reducing sleep-wake stage transitions and stage bouts, together with increasing stage durations. Furthermore, daily administration of melatonin at 9 a.m. significantly increased the nonrapid eye movement sleep delta power during both the light and dark periods and decreased the degree of reduction of the circadian index.

CONCLUSIONS

Melatonin promptly reversed ischemia-induced sleep disturbances. The neuroprotective effects of melatonin on ischemic injury may be partially associated with its role in sleep modulation.

Self-Reported and Objective Sleep Measures in Stroke Survivors With Incomplete Motor Recovery at the Chronic Stage

Background. Stroke survivors commonly complain of difficulty sleeping. Poor sleep is associated with reduced quality of life and more understanding of long-term consequences of stroke on sleep is needed. Objective. The primary aims were to (1) compare sleep measures between chronic stroke survivors and healthy controls and (2) test for a relationship between motor impairment, time since stroke and sleep. Secondary aims were to explore mood and inactivity as potential correlates of sleep and test the correlation between self-reported and objective sleep measures. Methods. Cross-sectional sleep measures were obtained for 69 chronic stroke survivors (mean 65 months post-stroke, 63 years old, 24 female) and 63 healthy controls (mean 61 years old, 27 female). Self-reported sleep was assessed with the sleep condition indicator (SCI) and sleep diary ratings, objective sleep with 7-nights actigraphy and mood with the Hospital Anxiety and Depression Scale. Upper extremity motor impairment was assessed with the Fugl-Meyer assessment. Results. Stroke survivors had significantly poorer SCI score (P < .001) and higher wake after sleep onset (P = .005) than controls. Neither motor impairment, nor time since stroke, explained significant variance in sleep measures for the stroke group. For all participants together, greater depression was associated with poorer SCI score (R²_adj = .197, P < .001) and higher age with more fragmented sleep (R²_adj = .108, P < .001). There were weak correlations between nightly sleep ratings and actigraphy sleep measures (r_s = .15-.24). Conclusions. Sleep disturbance is present long-term after stroke. Depressive symptoms may present a modifiable factor which should be investigated alongside techniques to improve sleep in this population.

Sleep disturbance predicts future health status after stroke

STUDY OBJECTIVES

We evaluated factors associated with the presence of sleep disturbance in patients with stroke and whether sleep disturbance predicted change in other patient-reported domains of health over time.

METHODS

Observational cohort study of 2,190 patients with stroke seen in a cerebrovascular clinic February 17, 2015 to July 5, 2017 who completed patient-reported outcome measures (PROMs) at ≥ 1 visit, including the Patient Health Questionnaire-9 depression screen, Quality of Life in Neurological Disorders (NeuroQoL) cognitive function and Patient-Reported Outcomes Information Measurement System (PROMIS) sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. Separate multivariable models were constructed with PROMIS sleep disturbance as the dependent variable. Covariates included clinical and demographic variables, the Patient Health Questionnaire-9 depression screen scored on the PROMIS metric, and 1 of the 6 other PROMs. Among the 476 patients with ≥ 2 visits, linear regression models were constructed to determine the association of baseline sleep disturbance with follow-up PROMs after adjustment for the corresponding baseline PROMIS/NeuroQol scores, depression score, and clinical variables.

RESULTS

Younger age and all PROM scores were associated with sleep disturbance; depression had the greatest association among PROMs (beta estimate 0.53, 95% confidence interval, 0.49, 0.57), physical function had the least (-0.06, 95% confidence interval, -0.11, -0.01). Baseline PROMIS sleep disturbance score was associated with worse adjusted follow-up scores for depression, fatigue, social role satisfaction, and physical function.

CONCLUSIONS

Younger age and all 8 PROMs were associated with sleep disturbance in patients with stroke. The degree of sleep disturbance predicted future patient-reported outcomes for multiple domains of health. Further study is warranted to determine if interventions shown to improve sleep symptoms will also improve other outcomes.

Social support and sleep quality in patients with stroke: The mediating roles of depression and anxiety symptoms

BACKGROUND

Research has demonstrated that higher social support is associated with better psychological health, quality of life, cognition, activities of daily living and social participation, but the relationship between social support and sleep quality remains unknown.

AIMS

This study aimed to assess the incidence of poor sleep quality, clarify the relationship between social support and sleep quality amongst stroke patients and determine whether anxiety and depression symptoms mediate this relationship.

METHODS

We conducted a quantitative, cross-sectional study involving 238 patients with stroke (median age of 61 [range 29-87] years, 68.1% male) recruited from a comprehensive tertiary care hospital between September 2019 and January 2020. A self-administered, structured questionnaire was used for the survey. The mediating effect of anxiety and depression symptoms was assessed using the bootstrap method via Model 4 (parallel mediation) of the SPSS PROCESS macro.

RESULTS

Results showed that the incidence of poor sleep quality amongst stroke patients was 65%. Mediation analysis showed that social support exerted significant direct effects on sleep quality, and anxiety and depression symptoms mediated the relationship between social support and sleep quality.

CONCLUSION

Measures should be taken to enhance social support to improve the sleep quality of stroke patients.

SUMMARY STATEMENT

What is already known about this topic? Patients with stroke have a high rate of sleep disorders, anxiety and depression symptoms. Anxiety and depression symptoms have a negative effect on sleep quality. Social support may be an effective intervention to reduce anxiety and depression symptoms and improve sleep quality amongst stroke patients. What this paper adds? The incidence of poor sleep was high amongst stroke patients. Social support had a direct positive effect on sleep quality. Anxiety and depression symptoms played multiple mediating roles in the relationship between social support and sleep quality. The implications of this paper: Our study adds to the existing literature by clarifying how social support impacts the sleep quality of stroke patients. We suggested improving the sleep quality of stroke patients through enhancing social support and reducing anxiety and depression symptoms, especially in patients with low levels of social support.

Insomnia in neurological diseases

Insomnia is defined as difficulties of initiating and maintaining sleep, early awakening and poor subjective sleep quality despite adequate opportunity and circumstances for sleep with impairment of daytime performance. These components of insomnia - namely persistent sleep difficulties despite of adequate sleep opportunity resulting in daytime dysfunction - appear secondary or co-morbid to neurological diseases. Comorbid insomnia originates from neurodegenerative, inflammatory, traumatic or ischemic changes in sleep regulating brainstem and hypothalamic nuclei with consecutive changes of neurotransmitters. Symptoms of neurological disorders (i.e motor deficits), co-morbidities (i.e. pain, depression, anxiety) and some disease-specific pharmaceuticals may cause insomnia and/or other sleep problems.This guideline focuses on insomnias in headaches, neurodegenerative movement disorders, multiple sclerosis, traumatic brain injury, epilepsies, stroke, neuromuscular disease and dementia.The most important new recommendations are: Cognitive behavioral therapy (CBTi) is recommended to treat acute and chronic insomnia in headache patients. Insomnia is one of the most frequent sleep complaints in neurodegenerative movement disorders. Patients may benefit from CBTi, antidepressants (trazodone, doxepin), melatonin and gaba-agonists. Insomnia is a frequent precursor of MS symptoms by up to 10 years. CBTi is recommended in patients with MS, traumatic brain injury and. Melatonin may improve insomnia symptoms in children with epilepsies. Patients with insomnia after stroke can be treated with benzodiazepine receptor agonists and sedating antidepressants. For patients with dementia suffering from insomnia trazodone, light therapy and physical exercise are recommended.

Bed Sensor Technology for Objective Sleep Monitoring Within the Clinical Rehabilitation Setting: Observational Feasibility Study

Background

Since adequate sleep is essential for optimal inpatient rehabilitation, there is an increased interest in sleep assessment. Unobtrusive, contactless, portable bed sensors show great potential for objective sleep analysis.

Objective

The aim of this study was to investigate the feasibility of a bed sensor for continuous sleep monitoring overnight in a clinical rehabilitation center.

Methods

Patients with incomplete spinal cord injury (iSCI) or stroke were monitored overnight for a 1-week period during their in-hospital rehabilitation using the Emfit QS bed sensor. Feasibility was examined based on missing measurement nights, coverage percentages, and missing periods of heart rate (HR) and respiratory rate (RR). Furthermore, descriptive data of sleep-related parameters (nocturnal HR, RR, movement activity, and bed exits) were reported.

Results

In total, 24 participants (12 iSCI, 12 stroke) were measured. Of the 132 nights, 5 (3.8%) missed sensor data due to Wi-Fi (2), slipping away (1), or unknown (2) errors. Coverage percentages of HR and RR were 97% and 93% for iSCI and 99% and 97% for stroke participants. Two-thirds of the missing HR and RR periods had a short duration of ≤120 seconds. Patients with an iSCI had an average nocturnal HR of 72 (SD 13) beats per minute (bpm), RR of 16 (SD 3) cycles per minute (cpm), and movement activity of 239 (SD 116) activity points, and had 86 reported and 84 recorded bed exits. Patients with a stroke had an average nocturnal HR of 61 (SD 8) bpm, RR of 15 (SD 1) cpm, and movement activity of 136 (SD 49) activity points, and 42 reported and 57 recorded bed exits. Patients with an iSCI had significantly higher nocturnal HR (t₁₈=−2.1, P=.04) and movement activity (t₁₈=−1.2, P=.02) compared to stroke patients. Furthermore, there was a difference between self-reported and recorded bed exits per night in 26% and 38% of the nights for iSCI and stroke patients, respectively.

Conclusions

It is feasible to implement the bed sensor for continuous sleep monitoring in the clinical rehabilitation setting. This study provides a good foundation for further bed sensor development addressing sleep types and sleep disorders to optimize care for rehabilitants.

Impact of Obstructive Sleep Apnea on In-Hospital Outcomes of Patients with Non-ST Elevation Myocardial Infarction

Background: Obstructive sleep apnea (OSA) is one of the most common breathing disorders. There are uncertainties about its impact on the in-hospital outcomes of patients who suffer acute coronary syndromes. We studied the largest publicly available all-payer inpatient healthcare database in the United States (National Inpatient Sample) to determine the effects of obstructive sleep apnea on the in-hospital outcomes of patients admitted with non-ST elevation myocardial infarction (NSTEMI). Methods: All adult patients (age ≥ 18) admitted primarily for NSTEMI between September 2010 and September 2015 were identified in the National Inpatient Sample. They were then categorized into those with OSA and those without OSA. The main outcome was in-hospital mortality. Propensity scoring and logistic regression models were created to determine the outcomes. Results: There were 1,984,432 patients with NSTEMI (weighted estimates), 123,551 (6.23%) of who had diagnosed OSA while 1,860,881 (93.77%) did not. In-hospital mortality was significantly lower in the OSA group [2.61% vs. 3.53%, adjusted odd ratio (aOR) 0.73 and confidence interval (CI) (0.66–0.81)]. Patients with OSA were also less likely to require coronary artery bypass surgery: 13.85% and 12.77% (p-value 0.0003). The patients with OSA had higher mean hospital costs compared to the patients who did not have OSA: $17,326 vs. $16,984, adjusted mean ratio (aMR) 1.02; CI (1.01–1.02). Conclusion: In-hospital mortality was lower in NSTEMI patients with diagnosed OSA compared to patients without diagnosed OSA. This appears to contrast with the widely recognized adverse effects of OSA on the cardiovascular system.

The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis

Background

Adequate sleep is vital for health and quality of life. People with stroke and a concomitant sleep disorder may have poorer outcomes than those without a sleep disorder.

Objective

To systematically evaluate the published literature to determine the impact of sleep disorders on physical, functional recovery at the activity and participation level after stroke.

Methods

A systematic review was conducted using PubMed, CINAHL, Scopus, and PsycINFO. Studies were selected that reported outcomes on physical, functional recovery at the activity and participation levels in participants with stroke and a diagnosed sleep disorder. A meta-analysis was performed on included studies that reported Barthel Index (BI) and modified Rankin Scale (mRS) scores. Results: A total of 33 studies were included in the systematic review with 9 of them in the meta-analysis. The mean mRS score was 0.51 points higher in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: 0.23-0.78]. The mean BI score was 10.2 points lower in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: −17.9 to −2.6].

Conclusions

People with stroke and a sleep disorder have greater functional limitations and disability than those without a sleep disorder. Rehabilitation professionals should screen their patients with stroke for potential sleep disorders and further research is needed to develop sleep and rehabilitation interventions that can be delivered in combination. PROSPERO registration number: CRD42019125562.

Relationship between SDB and short-term outcome in Finnish ischemic stroke patients

OBJECTIVES

Presence of sleep-disordered breathing (SDB) affects negatively recovery from stroke. The aim of this study is to evaluate the relationships between sleep-disordered breathing (SDB) and outcome measures in Finnish stroke unit cohort: mRS, need of rehabilitation and hospitalization time.

MATERIAL AND METHODS

An observational longitudinal study consisted of 95 patients referred to the Stroke Unit of Satakunta Hospital District over a period of November 2013 to March 2016. Patients were tested for SDB within 72 hr from the hospital admission because of ischemic stroke or TIA. The patients underwent polysomnography with NOX T3 wireless recorder.

RESULTS

There are 37% (n = 35) non-OSA patients, 20% (n = 19) of patients have mild obstructive sleep apnea (OSA) and 39% (n = 37) have moderate/severe OSA and 4% (n = 4) have CSA. Patients with OSA have higher proportion of disability scores of mRS 3-5 (38%) compared to non-OSA (11%) and mild OSA (5%) patients on registration day (mRS0), and the same trend is seen at hospital discharge 35% versus 9% and 5%. (p = .009). Proportion of patients with OSA who needed rehabilitation is 65% (n = 19) versus non-OSA patients 17.5% (n = 4) and mild OSA patients 17.5% (n = 4; p = .039). We observed longer duration of hospitalization (5-15 days) in 29% of OSA patients compared to mild OSA patients 47% and OSA patients 54%. (p = .045).

CONCLUSION

Ischemic stroke patients with OSA have higher disability, higher need of rehabilitation, and longer hospitalization length. Prescreening tools for recognizing these stroke patients in acute phase could be valuable. That could result in earlier initiation of treatment and might prevent worse recovery from stroke.

Development of a Care Bundle for Stroke Survivors with Psychological Symptoms: Evidence Summary and Delphi Study

Background

Psychological symptoms such as depression and anxiety are quite common among stroke survivors and have great negative impacts on patients.

Objective

To develop a care bundle through reviewing and integrating care strategies for psychological symptoms after stroke and then improve the bundle by Delphi study.

Methods

A structured search of the literature was performed to identify studies evaluating interventions for stroke patients with psychological symptoms such as depression and anxiety. Two trained researchers screened papers through the titles, abstracts, and full-texts independently. All studies complying with the eligibility criteria were appraised using quality assessment tools. Related interventions with evaluated evidence levels formed the preliminary bundle. Afterward, the Delphi study was carried out to improve the bundle, and the experts were contacted by e-mail. Ten clinical experts specialized in stroke and psychological rehabilitation were recruited. The reliability of experts was represented by the effective response rate and authority coefficient (Cr). The consensus was deemed to be reached when the mean score for item importance is all equal or above 3.50 and the coefficient of variation (CV) is all equal or below 0.20. The Kendall coefficient W test was adopted to evaluate the consensus on agreement among the experts as well. Data analysis was performed using SPSS V.22.0.

Results

Through a systematic evidence summary and two-round Delphi study, the items that were given high scores and got consensus by experts were chosen for the bundle. The iDAME bundle consisted of five interventions eventually: maintaining Interaction, tailored Diet, Acupressure, mindfulness Meditation, and physical Exercise.

Conclusion

The development of an evidence-based and consensus-based iDAME bundle which integrated western and traditional Chinese medicine intervention was described. Evidence summary made the bundle become scientific, while the Delphi study made it more maneuverable. Based on these results, the bundle would be potentially implemented in stroke patients for their psychological symptoms.

Impairment of cognition and sleep after acute ischaemic stroke or transient ischaemic attack in Chinese patients: design, rationale and baseline patient characteristics of a nationwide multicentre prospective registry

BACKGROUND AND AIM

Cognitive impairment and sleep disorder are both common poststroke conditions and are closely related to the prognosis of patients who had a stroke. The Impairment of CognitiON and Sleep after acute ischemic stroke or transient ischemic attack in Chinese patients (ICONS) study is a nationwide multicentre prospective registry to investigate the occurrence and associated factors of cognitive impairment and sleep disorder after acute ischaemic stroke (AIS) or transient ischaemic attack (TIA).

METHODS

Consecutive AIS or TIA in-hospital patients within 7 days after onset were enrolled from 40 participating sites in China. Comprehensive baseline clinical and imaging data were collected prospectively. Blood and urine samples were also collected on admission and follow-up visits. Patients were interviewed face to face for cognition and sleep related outcomes at 2 weeks, 3, 6 and 12 months after AIS/TIA and followed up for clinical outcomes by telephone annually over 5 years.

RESULTS

Between August 2015 and January 2018, a total of 2625 patients were enrolled. 92.65% patients had AIS and 7.35% patients had TIA. Overall, the average age was 61.04 years, and 72.38% patients were male. Median National Institutes of Health Stroke Scale score was 3 in AIS patients.

CONCLUSIONS

The ICONS study is a large-scale nationwide prospective registry to investigate occurrence and the longitudinal changes of cognitive impairment and sleep disorder after AIS or TIA. Data from this registry may also provide opportunity to evaluate associated factors of cognitive impairment or sleep disorder after AIS or TIA and their impact on clinical outcome.

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

Sleep-related symptoms in patients with mild stroke

STUDY OBJECTIVES

Treatable sleep-related conditions are frequent in stroke patients, although their prevalence across stroke types and ideal method for screening is not clear. The objectives of this study were to evaluate the prevalence of sleep disturbance across different stroke types and identify approaches to the collection of sleep-related measures in clinical practice.

METHODS

We performed an observational cohort study of 2,213 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or transient ischemic attack seen in a cerebrovascular clinic February 17, 2015 through July 5, 2017 who completed at least one of the following sleep-related questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance, Insomnia Severity Index (ISI), Sleep Apnea Probability Scale (SAPS), and sleep duration. Prevalence of abnormal scores were calculated using the following thresholds: PROMIS sleep disturbance ≥ 55, ISI ≥ 15, SAPS score ≥ 0.50, and sleep duration fewer than 6 or more than 9 hours. Sensitivity, specificity, and positive and negative predictive values of PROMIS sleep disturbance T-score ≥ 55 to identify patients with moderate-severe insomnia (ISI ≥ 15) were computed.

RESULTS

In the cohort, 28.6% patients (624/2183) had PROMIS sleep disturbance score ≥ 55, 17.6% (142/808) had ISI ≥ 15, and 61.3% (761/1241) had a positive SAPS screen. The frequency of abnormal sleep scale scores was similar across time periods and stroke types. The sensitivity and specificity of PROMIS sleep disturbance T-score ≥ 55 to identify patients with ISI ≥ 15 were 0.89 (95% confidence interval 0.83-0.94) and 0.81 (95% confidence interval 0.78-0.84), respectively.

CONCLUSIONS

The prevalence of sleep-related symptoms in patients with mild stroke are similar across stroke types and time periods after stroke. Potential approaches to screening for sleep disturbance in stroke patients are provided.

Evaluation of an OSA risk stratifying and treatment protocol during inpatient rehabilitation of post-stroke patients

PURPOSE

To evaluate outcomes, outside of a clinical trial setting, of a protocol utilizing overnight oximetry (NOx) to risk stratify post-stroke patients for obstructive sleep apnea (OSA) followed by autoadjusting continuous positive airway pressure (APAP) treatment in patients considered high risk for OSA.

METHODS

Retrospective observational study of post-stroke patients at an academic inpatient stroke rehabilitation facility. Patients underwent NOx, and those at high risk for OSA (oxygen desaturation index 3% > 10 per hour) were attempted on a trial of APAP, and further stratified into high risk adherent with treatment (HRAT) or high-risk failed treatment (HRFT). Change in functional independence measure (FIM) was used to assess recovery.

RESULTS

Two hundred twenty-four post-stroke patients underwent NOx, with 120 (53%) considered high risk for OSA. Twelve (10%) were compliant with APAP treatment (> 4 h/night on > 70% of nights). No difference in change in FIM scores was observed for HRAT versus HRFT [total FIM change - 5.8, 95% CI (- 13.9, 2.2); motor FIM change - 4.5, 95% CI (- 11.5, 2.4); cognitive FIM change - 1.3, 95% CI (-3.8, 1.2)]. A subgroup analysis matched 14 HRAT patients (using adherence criterion of APAP usage > 50% of nights) to 35 HRFT patients. A statistically significant, but clinically irrelevant, difference in total FIM change was observed (HRAT vs HRFT, difference between means - 5.2, p = 0.03).

CONCLUSIONS

The use of APAP in high-risk patients was poorly tolerated and did not improve post-stroke recovery. Further studies with larger sample sizes are needed to determine the effect of APAP treatment on short-term recovery.