Obstructive sleep apnea syndrome in adults with down syndrome: Causes and consequences. Is it a "chicken and egg" question?

Age of Alzheimer's disease diagnosis in people with Down syndrome and associated factors: Results from the Horizon 21 European Down syndrome consortium

INTRODUCTION

People with Down syndrome (DS) have high risk of developing Alzheimer's disease (AD). This study examined mean ages of AD diagnosis and associations with co-occurring conditions among adults with DS from five European countries.

METHODS

Data from 1335 people with DS from the Horizon 21 European DS Consortium were used for the analysis.

RESULTS

Mean ages of AD diagnosis ranged between 51.4 (SD 7.0) years (United Kingdom) and 55.6 (SD 6.8) years (France). Sleep-related and mental health problems were associated with earlier age of AD diagnosis. The higher number of co-occurring conditions the more likely the person with DS is diagnosed with AD at an earlier age.

DISCUSSION

Mean age of AD diagnosis in DS was relatively consistent across countries. However, co-occurring conditions varied and impacted on age of diagnosis, suggesting that improvements can be made in diagnosing and managing these conditions to delay onset of AD in DS.

HIGHLIGHTS

Mean age of AD diagnosis was relatively consistent between countries Sleep problems and mental health problems were associated with earlier age of AD diagnosis APOE ε4 carriers were diagnosed with AD at an earlier age compared to non-carriers Number of co-occurring conditions was associated with earlier age of AD diagnosis No differences between level of intellectual disability and mean age of AD diagnosis.

[Use of murine models for the study of obstructive sleep apnea syndrome in Down syndrome]

Down syndrome (DS), or trisomy 21, is a genetic disorder caused by the presence of an extra copy of chromosome 21, leading to various characteristic physical features as well as developmental and cognitive delays. Obstructive sleep apnea syndrome (OSAS) is a common disorder in both adult and pediatric patients with DS. Several characteristics of DS may contribute to the development or worsening of OSAS. Numerous murine models of DS exist. A number of studies have explored apneas and the risk of upper airway obstruction in these models, but up until now, only in adulthood.

Long-Term Outcomes in Patients With Trisomy 21 and Obstructive Sleep Apnea

OBJECTIVE

To better understand the long-term health implications of obstructive sleep apnea (OSA) on patients with Trisomy 21 (T21) and the role of sleep surgery as a therapeutic intervention.

STUDY DESIGN

Retrospective large database review.

SETTING

The prevalence of OSA is as high as 75% in patients with T21. We sought to examine the cardiovascular, neurological, and endocrinological outcomes of patients with T21 10 years after their diagnosis of OSA.

METHODS

TriNetX, an electronic medical record database, was queried for health outcomes in patients with T21 after diagnosis of OSA. The group was further analyzed to identify those who underwent sleep surgery, including hypoglossal nerve stimulation, palatopharyngoplasty, or adenotonsillectomy.

RESULTS

Ten years after diagnosis, patients with OSA and T21 had a significantly higher incidence of death, myocardial infarction, cerebral infarction, heart failure, cardiac arrhythmia, ischemic heart disease, atrial fibrillation, essential hypertension, pulmonary hypertension, diabetes mellitus, and Alzheimer's disease compared to patients with T21 alone. Patients with OSA and T21 who underwent sleep surgery had significantly reduced incidence of adverse health outcomes compared to patients using continuous positive airway pressure.

CONCLUSION

Our findings suggest that patients with T21 and OSA are at higher risk of poor health outcomes, which may require closer monitoring for earlier diagnosis and management of comorbid conditions. Sleep surgery is a suitable treatment modality for mitigating the risk of adverse outcomes in this population and should be considered in patients who are eligible surgical candidates.

Sleep Problems Before and During the COVID-19 Pandemic in Children with Autism Spectrum Disorder, Down Syndrome, and Typical Development

Sleep problems are common in children and adolescents, particularly those with Neurodevelopmental Disorders. With the changes in daily habits resulting from the COVID-19 pandemic, we have analyzed sleep characteristics, during social isolation, in Brazilian children and adolescents aged between 4 and 12 years with Autism Spectrum Disorder (N = 267), Down Syndrome (N = 74), and typical development (N = 312). The ASD group presented with worse indicators of sleep habits in the Children's Sleep Habits Questionnaire (CSHQ-BR) and fell asleep later during the pandemic. The entire group started fall asleep and waking up later during the pandemic - as well as waking up more often during the night. These results may contribute to parental guidance and sleep habit-related interventions during and after the COVID-19 pandemic.

Insomnia Symptoms Are Associated with Measures of Functional Deterioration and Dementia Status in Adults with Down Syndrome at High Risk for Alzheimer's Disease

Background

While obstructive sleep apnea (OSA) and insomnia symptoms in neurotypical populations are associated with Alzheimer's disease (AD), their association with dementia in adults with Down syndrome (DS) remains less clear, even though these symptoms are prevalent and treatable in DS. Understanding their associations with AD-related dementia status, cognitive impairment, and functional deterioration may lead to interventions to slow decline or disease progression in adults with DS.

Objective

To characterize differences in OSA and insomnia symptom expression by dementia status, and to determine which sleep factors support dementia diagnosis.

Methods

Multimodal consensus conference was used to determine dementia status in 52 adults with DS (52.2 ± 6.4 years, 21 women). Cognitive impairment, adaptive behavior skills, and symptoms of OSA and insomnia were quantified using validated assessments for adults with DS and their primary informants.

Results

A sex by dementia status interaction demonstrated that older women with DS and dementia had more severe terminal insomnia but not OSA symptoms relative to older women with DS who were cognitively stable (CS). Greater insomnia symptom severity was associated with greater functional impairments in social and self-care domains adjusting for age, sex, premorbid intellectual impairment, and dementia status.

Conclusions

Insomnia symptoms are more severe in women with DS with dementia than in women with DS and no dementia, and regardless of dementia status or sex, more severe insomnia symptoms are associated with greater impairment in activities of daily living. These findings underscore the potential importance of early insomnia symptom evaluation and treatment in women with DS at risk of developing AD.

Adherence to CPAP therapy in Down syndrome: the population-based DISCOVERY study

STUDY OBJECTIVES

Persons with Down syndrome (DS) have an increased risk of obstructive sleep apnea (OSA) needing continuous positive airway pressure (CPAP), but data on the therapy and outcomes in this population are scarce. We aimed to compare patient characteristics and outcomes of CPAP treatment for patients with OSA with and without DS.

METHODS

This was a population-based, longitudinal study on patients initiating CPAP therapy between July 2010 and March 2018 in Sweden and a population-based sex- and age-matched control group (control:case ratio 5:1), with linked data from the Swedish National Patient Registry and the Prescribed Drug Registry (DISCOVERY study cohort).

RESULTS

Patients with DS (n = 64) had a higher apnea-hypopnea index (51.7 ± 30.3 vs 36.8 ± 29.1 events/h, P < .001), Epworth Sleepiness Scale score (13.7 ± 5.9 vs 11.0 ± 4.9, P = .001), rate of previous surgery of tonsils and/or adenoids (21.9% vs 8.2%, P = .001), and more thyroid replacement hormone therapy (45.3% vs 7.8%, P < .001), but lower use of cardiovascular drugs (7.8% vs 22.3%, P = .003) compared with controls. At follow-up after 1.3 ± 0.9 years, there were no differences in nocturnal CPAP usage time (5.6 ± 2.4 vs 5.5 ± 2.0 hours, P = .77), CPAP adherence ≥ 4 hours/night (62% vs 65%, P = .93), or improvement in Epworth Sleepiness Scale score (-5.4 ± 6.8 vs -5.0 ± 2.0, P = .84) between DS and non-DS patients.

CONCLUSIONS

OSA severity was substantially higher in patients with DS despite an increased rate of tonsil surgery. Treatment outcomes in terms of adherence and improved daytime sleepiness were comparable between groups, underlining the importance of both OSA diagnosis and treatment in patients with DS.

CITATION

Svensson M, Ekström M, Sundh J, Ljunggren M, Grote L, Palm A. Adherence to CPAP therapy in Down syndrome: the population-based DISCOVERY study. J Clin Sleep Med. 2023;19(3):453-458.

Sleep apnea in people with Down syndrome: Causes and effects of physical activity?

Poor sleep quality is recognized as a major risk factor for poor health, increasing the incidence of serious chronic diseases. In people with Down syndrome, sleep apnea prevalence is significantly greater, it is caused by genetic, anatomical, endocrine, and metabolic abnormalities. The consequences of sleep disruption due to sleep apnea are very serious, especially in terms of neurocognitive and cardiovascular effects, leading to reduced life expectancy and quality of life in this population. However, the management, care, and treatment of related disorders in people with Down syndrome are still inadequate and limited. Therefore, this article wants to increase understanding and awareness about sleep apnea and the benefits of physical activity in improving sleep quality in the Down syndrome community, families, and their care specialists.

Caregiver knowledge of obstructive sleep apnoea in Down syndrome

BACKGROUND

Down syndrome (DS) population has a very high prevalence of obstructive sleep apnoea (OSA), but this remains underdiagnosed. Hence, we aimed to evaluate caregiver's knowledge of OSA and related sociodemographic factors that could contribute to OSA screening patterns in this population.

METHODS

An online survey though the LuMind IDSC Foundation focused on OSA diagnosis, treatments and the number of sleep studies performed. Data were compared between subjects born before and after the American Academy of Pediatrics (AAP) recommendations for OSA screening.

RESULTS

Of the caregivers, 724 (parents 96.3%), responded to the survey. The median [interquartile (IQR)] age of the subjects with DS was 12 [20;7] years. The majority (84.3%) had sleep apnoea diagnosis, and half of them were initially referred for a sleep study due to disturbed sleep symptoms. Only 58.7% of the responders were aware of the AAP recommendations. This was linked to higher socioeconomic and/or educational level and to an earlier OSA diagnosis. The median (IQR) age of OSA diagnosis was lowered after the AAP guidelines publication compared with before its publication (3 [4;2] years vs. 10 [18;5] years, P < 0.000). Adenotonsillectomy (81.9%) and continuous positive airway pressure (61.5%) were the most commonly prescribed treatments. Few had discussed other new therapies such as hypoglossal nerve stimulation (16.0%). Only 16.0% of the subjects repeated the sleep study to monitor OSA with ageing, and 30.2% had to wait more than 4 years between studies.

CONCLUSIONS

This study reinforces the need to improve OSA knowledge of caregivers and clinicians of individuals with DS to promote an earlier diagnosis and optimal treatment of OSA in this population.

Down syndrome: orofacial pain, masticatory muscle hypotonia, and sleep disorders

The aim of the present study was to investigate orofacial pain in individuals with Down syndrome (DS) and determine possible associations with masticatory muscle hypotonia (MMH), maximum mouth opening (MMO), and sleep disorders. Twenty-three individuals with DS underwent a standardized clinical examination using Axis I of the Diagnostic Criteria for Temporomandibular Disorders, for the diagnosis of pain in the masseter and temporal muscles and temporomandibular joint (TMJ). MMH was investigated using electromyography of the temporal and masseter muscles and the measurement of maximum bite force (MBF). MMO was measured using an analog caliper. Sleep disorders (obstructive sleep apnea [OSA], snoring index [SI], and sleep bruxism index [SBI]) were investigated using type II polysomnography. Statistical analysis was performed. Nonsignificant differences were found in muscle and TMJ pain between the sexes. However, myalgia and referred myofascial pain in the left masseter muscle were more frequent in males (69%) than females (40%). Electrical activity of the temporal (left: p = .002; right: p = .004) and masseter (left: p = .008) muscles was significantly lower in males than in females. MBF range was lower in males than females, indicating the highest MMH among males. OSA, SI, and SBI were identified in both sexes, but with no statistically significant differences. We concluded that myalgia and referred myofascial pain were found in some individuals with DS, especially in males. Arthralgia was found mainly in females. Temporal and masseter myalgia may have exerted an influence on the severity of MMH in males, particularly on the left side.

Role of Adenotonsillectomy and Tonsillectomy in Children with Down Syndrome Who Develop Obstructive Sleep Apnea by Obesity as a Risk Factor

Down syndrome (DS) or trisomy 21 is caused due to the presence of additional chromosome 21 in humans. DS can exist either as free trisomy 21 (nondisjunction), Robertsonian translocated DS, or as mosaic DS. Obstructive sleep apnea (OSA) is a complex condition with serious health implications for pediatric individuals with DS. OSA is common in DS, and when it is present, it appears to be extreme. Obesity and snoring are some of the OSA risk factors for children associated with DS and OSA. Adenotonsillectomy is one of the surgical protocols applied in children, which is useful in lowering the OSA in which obesity is commonly connected within normal and DS children. Tonsillectomy is the alternative procedure of surgery connected with postoperative respiratory complications, and adenotonsillectomy was found to be a safe surgical method in children and improves the quality of life. The main aim of this review is to bridge the gap between the role of OSA in normal children (46, XX/XY) and DS children (47, XX/XY+21) characterized by the presence of chromosomes and exactly what is the involvement with adenotonsillectomy and tonsillectomy when obesity is a risk factor. The treatment for OSA and obesity is rehabilitative and reversible; however, DS can be managed but not resolved because the disorder occurs from the existence of an extra chromosome during the failure of homologous chromosomal pairing separation during maternal meiosis I. This review concludes that there is a treatment for OSA and obesity and that DS children can be prevented from being obese or experiencing OSA but cannot be turned to normal chromosomes due to an extra trisomy 21. According to this review, children with DS and OSA/OSAS, as well as concomitant complications, can be treated.

Obstructive sleep apnea in children with Down syndrome: is it possible to predict severe apnea?

The objectives are to explore the demographic and polysomnographic features of children with Down syndrome and to determine the predictive factors associated with severe sleep apnea. A total of 81 children with Down syndrome referred for full-night polysomnography were analyzed. In addition, parental interviews were performed for each child. Data were available for 81 children, with a mean age of 4.8 years. Severe obstructive sleep apnea was determined in 53.1%. Age, sex, exposure to second-hand smoke, clinical findings, anthropometric features, and the presence of comorbidities were not predictors of severe obstructive sleep apnea. Children who were exposed to second-hand smoke had more sleep-related symptoms. Even in children without symptoms, the prevalence of severe obstructive sleep apnea was 40%. Moreover, 86% of parents had no previous information regarding possible sleep breathing disorders in their children. Clinically significant central apnea was present in 10 patients (12.3%).Conclusion: Our results demonstrate that severe obstructive sleep apnea is common in children with Down syndrome, even in children without a history of symptoms of sleep apnea. It is not possible to predict patients with severe apnea; thus, screening of children with Down syndrome beginning from young ages is very important. Central apneas could be a part of the spectrum of sleep abnormalities in Down syndrome.

Classification of Factors Effect on Sleep in Individuals with Down Syndrome

BACKGROUND

Sleep disordered breathing (SDB) is a frequent disorder with serious adverse health consequences in people with Down syndrome (DS). This study aims to evaluate and classify sleep and physical activity (PA) characteristics in adults with DS.

METHODS

Forty participants with DS wore an accelerometer for seven consecutive days to measure physical activity and sleep-wake patterns. The corresponding data were also obtained by survey and polysomnography. The apnea-hypopnea index (AHI) is calculated from the number of apneas and hypopneas per hour of sleep according to international guidelines.

RESULTS

Polysomnography showed SDB based on AHI in 95% of adults: 50% had severe SDB, 22.5% presented moderate and 22.5% mild SDB, predominantly in males. They had poor sleep quality (80.1%) and low PA levels. Using statistical classification methods, we observed three clusters with two opposite profiles. Clusters 2 and 3 showed low PA indices (daily steps: 5719 and 5310, respectively) and severe SDB (AHI = 33.6 and 55.5 events/h), high age and high gonial angle. Cluster 1 showed high PA (mean count of daily steps: 6908) and mild to moderate SDB (AHI = 16.8 events/h), low age and low gonial angle.

CONCLUSIONS

Our findings suggest that there are different profiles (age, gender, obesity, gonial angle) that are associated with SDB in adults with DS. These results suggest that this may represent important factors to consider when planning health promotion and prevention.

Association between sleep quality and physical functioning in adults with down syndrome: A brief report

BACKGROUND

Sleep quality is associated with physical functioning in adults, but this has not been examined in those with Down syndrome (DS). High body mass index (BMI) and accelerated aging, both common in adults with DS, may alter the relationship between sleep quality and physical functioning in this population.

OBJECTIVE

To examine sleep quality indicators and its association with physical functioning in adults with DS, and whether associations are altered by BMI and age.

METHODS

Participants were 15 adults with DS (8 women; age 29 ± 14 years). We evaluated sleep quality over seven days with wrist-worn accelerometers and physical functioning with the timed-up-and-go (TUG) and 6-min walk (6 MW) tests. We examined the associations between sleep quality and physical functioning variables using Spearman's rho.

RESULTS

Sleep quality indicators were: total sleep time 407 ± 54 min; latency 26.8 ± 21 min; efficiency 73.9 ± 12 %; wake after sleep onset 122.8 ± 65.2 min; number of awakenings 21.0 ± 6.2; and average length of awakenings 6.1 ± 3 min. Total sleep time and average length of awakenings were significantly associated with 6 MW distances (rho = 0.58 and -0.69; p < 0.05, respectively). After controlling for age and BMI, 6 MW distance was significantly associated with total sleep time, latency, efficiency, and average length of awakenings (rho = 0.56, -0.73, 0.60, and -0.87; p < 0.05, respectively). TUG was significantly associated with total time in bed (rho = 0.71); p < 0.05).

CONCLUSIONS

Sleep quality indicators are associated with walking performance in adults with DS. Age and BMI strengthen the relationship between sleep quality and physical functioning.

Sleep Disorders in Adults with Down Syndrome

Sleep disorders, despite being very frequent in adults with Down syndrome (DS), are often overlooked due to a lack of awareness by families and physicians and the absence of specific clinical sleep guidelines. Untreated sleep disorders have a negative impact on physical and mental health, behavior, and cognitive performance. Growing evidence suggests that sleep disruption may also accelerate the progression to symptomatic Alzheimer’s disease (AD) in this population. It is therefore imperative to have a better understanding of the sleep disorders associated with DS in order to treat them, and in doing so, improve cognition and quality of life, and prevent related comorbidities. This paper reviews the current knowledge of the main sleep disorders in adults with DS, including evaluation and management. It highlights the existing gaps in knowledge and discusses future directions to achieve earlier diagnosis and better treatment of sleep disorders most frequently found in this population.

Perioperative care of adults with Down syndrome: a narrative review

Because of enhanced life expectancy due to medical and surgical therapeutic advances, it is estimated that there are more adults than children living with Down syndrome (DS), or trisomy 21, in the United States. Therefore, DS can no longer be considered a syndrome limited to the pediatric population. These patients are presenting for surgery and anesthesia in adult care settings, where anesthesiologists will encounter these patients more frequently. As these patients age, their commonly associated co-morbidities not only progress, but they also develop other cardiac, respiratory, gastrointestinal, and neurologic conditions. The manifestations and consequences of chronic disease can present new challenges for the anesthesiologist and require expertise and judgement to minimize patient risk. The purpose of this narrative review is to describe the common pediatric co-morbidities associated with DS and discuss the age-acquired manifestations. Additionally, considerations for anesthetic care of the adult with DS will be presented, including the preoperative assessment, intraoperative management, and postoperative care.

Bruxism in Children and Adolescents with Down Syndrome: A Comprehensive Review

The role of bruxism in children and adolescents with Down syndrome, the most often diagnosed congenital syndrome, is still unclear. Therefore, this study aims to conduct a narrative review of the literature about bruxism in children and adolescents with Down syndrome to identify the prevalence, risk factors, and possible treatments of this disorder. Although an accurate estimate of its prevalence could not be inferred, it appears that bruxism is more prevalent in Down syndrome individuals rather than in the general pediatric population. No gender difference was observed, but a reduction in its prevalence was described with increasing age (around 12 years). The variability in the diagnostic techniques contributed to the heterogeneity of the literature data. Clinicopathological features of Down syndrome, such as muscle spasticity, oral breathing, and a predisposition to obstructive sleep apnea, may suggest a higher prevalence of bruxism in this patient group. Finally, given the paucity of studies on the management of bruxism in this population, it was not possible to outline a standard protocol for the non-invasive treatment of cases in which an observational approach is not sufficient.