Stroke and sleep apnoea: cause or consequence?

The ZJU index is associated with the risk of obstructive sleep apnea syndrome in Chinese middle-aged and older people: a cross-sectional study

BACKGROUND

The ZJU index, a novel calculation that combines body mass index, triglycerides, fasting blood glucose and the ratio of alanine aminotransferase to aspartate aminotransferase, is a closely related measure of obesity and insulin resistance. Studies of the ZJU index in relation to obstructive sleep apnea syndrome (OSAS) have not been reported. This study assessed the correlation between the ZJU values and OSAS risk.

METHODS

A total of 2,130 participants who underwent polysomnographic monitoring were included in the study. The participants' basic information and laboratory biochemical indicators were collected, and the ZJU index was computed. The ZJU index was divided into quartiles. The correlation between the different ZJU index levels and OSAS risk was assessed using logistic regression. Drew a receiver operating characteristic (ROC) relationship curve, with prediction efficacy judged by the area under the curve (AUC), and found the optimum cut-off point for ZJU index to predict OSAS. Relative risks were presented as odds ratios (OR). The range of OR values is expressed in the form of 95% confidence intervals (95% CI).

RESULTS

The number of patients diagnosed with OSAS increased progressively with increasing ZJU index (T1: 9.4%; T2: 20.6%; T3: 28.3%; T4: 41.7%; P < 0.001). The additional confounders were adjusted by the logistic regression models, the study revealed an independent correlation between ZJU index and OSAS. (P < 0.001). The OSAS risk was notably higher at the highest ZJU index levels. (OR = 2.046 [95% CI: 1.057 to 3.964]). The ROC curve for the ZJU index showed an AUC of 0.64 (P < 0.001) for males and 0.75 (P < 0.001) for females, with a specificity of 64% and 55% and a sensitivity of 60% and 92% for males and females, respectively, with the optimum cut-off values of 36.568 and 34.722, respectively.

CONCLUSION

A high ZJU index was significantly associated with an increasing risk of OSAS. The ZJU is expected to be a meaningful index for detecting OSAS in the general population.

Couples-based interventions to promote PAP adherence among older adults: a qualitative study of patients, partners, and providers

STUDY OBJECTIVES

Bed partners play a critical role in the treatment of obstructive sleep apnea and are affected by the treatment (or lack thereof) of their partner's obstructive sleep apnea, but few studies have included partners formally in treatment. In this qualitative study, we examine key stakeholder perspectives (patient, bedpartner, and sleep medicine provider) to inform the development of a novel, couples-based intervention to promote adherence to positive airway pressure (PAP) and sleep health among older adult couples.

METHODS

We conducted 3 focus group discussions with patients with obstructive sleep apnea/using PAP and their partners and 3 focus group discussions with sleep medicine providers. A standard interview guide was used to gather stakeholder input: (1) to understand interdependence of sleep among couples with sleep apnea; (2) to understand collaborative strategies that couples are currently using to address their sleep health challenges, including their perceptions of what is helpful vs not helpful; and (3) feasibility of the intervention design and delivery. Interviews were transcribed and thematically analyzed.

RESULTS

Participants (n = 25) included 9 patients, 7 partners, and 9 providers. Analysis of the discussion identified themes within the 3 topics addressed in the focus group discussions: (1) interdependence of sleep health among couples, (2) collaboration and other dyadic strategies for increasing PAP use, and (3) facilitators and barriers to a couples-based PAP adherence intervention. Results of the focus group discussions provided new insights into collaborative strategies that could be used to enhance the sleep health of both patients and partners. Patient/partners reported that a couples-based treatment could reduce common frustrations experienced by new PAP users, thereby benefiting their relationship. However, barriers to couples-based treatment included patients and partners feeling overwhelmed and reluctance to discuss intimacy. Providers recognized the benefits of involving partners but reported concern about exacerbating conflict in the couple.

CONCLUSIONS

Results indicate that couples and providers are enthusiastic about couples-based treatment that addresses their individual and dyadic sleep health challenges and identified important barriers that will need to be addressed to enhance uptake by clinicians and participation/retention of couples.

CITATION

Baron KG, Troxel WM, Galway S, et al. Couples-based interventions to promote PAP adherence among older adults: a qualitative study of patients, partners, and providers. J Clin Sleep Med. 2022;18(11):2627-2634.

Rationale and study protocol for We-PAP: a randomized pilot/feasibility trial of a couples-based intervention to promote PAP adherence and sleep health compared to an educational control

BACKGROUND

Obstructive sleep apnea (OSA) is a serious health condition that affects approximately 30-50% of older adults and contributes to risk for cardiometabolic disorders and dementia. Despite the well-documented role of partners in treatment seeking and adherence to positive airway pressure (PAP), treatments for OSA have nearly exclusively focused on the patient and current treatments for OSA do not address co-existing sleep problems such as insomnia that are prevalent in both patients with OSA and their partners. Therefore, the goal of this study is to develop and test a novel couples-based sleep health intervention to promote adherence to PAP and improve sleep health of the couple.

METHODS

We are conducting a two-arm, parallel group, single blind, randomized controlled pilot/feasibility trial to compare our novel couples-based sleep health intervention (We-PAP) to an information control group (IC). We-PAP is based on a transdiagnostic model and uses a dyadic approach including increasing effective partner support, communication skills, and couple-level goal-setting. We-PAP involves 3 sessions and delivered via telehealth in weekly sessions. The IC includes standardized patient educational materials. Both groups receive the usual follow-up with their medical team. The study involves assessments at pre-treatment, post-intervention (approximately 1 month after starting PAP and completing We-PAP sessions or IC) and 3 months after starting PAP. Our main outcomes are feasibility and acceptability ratings. Secondary outcomes include comparing We-PAP to IC for PAP adherence, sleep quality (self-report and objective) and cognitive measures.

DISCUSSION

We-PAP is the first couples-based transdiagnostic sleep health intervention for patients with OSA and their partners. Results of this study will be used to inform the design of a subsequent fully powered clinical trial. If successful, this intervention could significantly advance current clinical practice in the treatment of OSA and sleep health more comprehensively in older adults. Moreover, this intervention may be useful for improving sleep in other aging populations with multiple sleep and other health problems, including patients with chronic illnesses or those at risk for Alzheimer's disease and their caregivers.

TRIAL REGISTRATION

NCT04759157 . Date of registration: February 8, 2021. URL of trial registry record.

Capnography screening for sleep apnea in patients with acute stroke

Sleep apnea syndrome (SAS) is a prominent clinical feature in acute stroke patients. Diagnosis is usually established by polysomnography or cardio-respiratory polygraphy (CRP). Both diagnostic procedures produce high costs, are dependent on the access to a specialized sleep laboratory, and are poorly tolerated by patients with acute stroke. In this study we therefore investigated whether capnography may work as a simple screening tool in this context. In addition to conventional CRP, 27 patients with acute stroke were studied with capnography provided by our standard monitoring system. The trend graphs of the end-tidal CO(2) values (EtCO(2)) were used to determine the capnography-based estimate of the apnea-hypopnea index (AHI(CO2)). Index events were scored when the EtCO(2) value dropped for > 50% of the previous baseline value. We found that the AHI(CO2) correlated significantly with the apnea-hypopnea index measured with conventional CRP (AHI(CRP)) (r = 0.94; p < 0.001). An AHI(CO2) > 5 turned out to be highly predictive of an AHI(CRP) > 10. According to our findings, routinely acquired capnography may provide a reliable estimate of the AHI(CRP). The equipment needed for this screening procedure is provided by the monitoring systems of most intensive care units and stroke units where stroke patients are regularly treated during the first days of their illness. Therefore, early diagnosis of SAS in these patients is made substantially easier.

Obstructive sleep apnea syndrome (OSAS) and hypertension: pathogenic mechanisms and possible therapeutic approaches

Obstructive sleep apnea syndrome (OSAS), a chronic condition characterized by collapse of the pharynx during sleep, has been increasingly recognized as a health issue of growing importance over the last decade. Recently emerging evidence suggests that there is a causal link between OSAS and hypertension, and hypertension represents an independent risk factor in OSAS patients. However, the pathophysiological basis for patients with OSAS having an increased risk for hypertension remains to be elucidated. The main acute physiological outcomes of OSAS are intermittent hypoxia, intrapleural pressure changes, and arousal from sleep, which might induce endothelial dysfunction, sympathetic activation, renin-angiotensin-aldosterone system activation, lipid metabolism dysfunction, and increased oxidative stress. This brief review focuses on the current understanding of the complex association between OSAS and hypertension.

Prognosis and cardiovascular morbidity and mortality in prospective study of hypertensive patients with obstructive sleep apnea syndrome in St Petersburg, Russia

BACKGROUND

To assess the impact of obstructive sleep apnea-hypopnea syndrome (OSAHS) on prognosis and cardiovascular morbidity and mortality in relation to other major cardiovascular risk factors.

MATERIAL/METHODS

This prospective study recruited 234 patients from an out-patient clinic. Based on the Berlin questionnaire, 147 patients (90 males, mean age 52.1 ± 10.4 years) with highly suspected sleep breathing disorders were included in the study. Based on cardiorespiratory monitoring, patients were divided into 2 groups: 42 patients without sleep breathing disorders (SBD), and 105 patients with OSAHS. Among these, 12 patients started CPAP therapy and formed the third group.

RESULTS

The mean follow-up period was 46.4 ± 14.3 months. Event-free survival was lowest in the untreated OSAHS patients (log rank test 6.732, p = 0.035). In the non-adjusted regression model, OSAHS was also associated with a higher risk of cardiovascular events (OR = 8.557, 95% CI 1.142-64.131, p = 0.037). OSAHS patients demonstrated higher rates of hospitalization compared to the control group without SBD (OR 2.750, 95%CI 1.100-6.873, p = 0.04).

CONCLUSIONS

OSAHS hypertensive patients, and in particular, according to our model, patients with severe OSAHS (AHI ≥ 30/h), are at higher risk of fatal and non-fatal cardiovascular events. Moreover, untreated OSAHS patients demonstrate higher rates of hospitalization caused by the onset or deterioration of cardiovascular disease.

Cerebrovascular Diseases and Sleep-Disordered Breathing

Sleep-disordered breathing (SDB) is more probably the cause rather than the consequence of stroke because: apneas are essentially obstructive rather than central, the frequency of SDB is not different between transient ischemic attack and cerebral infarction; and previous excessive daytime sleepiness is significantly more frequent among stroke patients with SDB than those without. The presence of SDB in stroke patients could lead to a poor outcome. Pathophysiological relationships between strokes and SDB are multiple. Experimental and clinical studies have shown that both short- and long-term factors may play a role in increasing the susceptibility to stroke in patients with obstructive sleep apnea syndrome. The former include changes in cerebral hemodynamics, hematologic alterations, and cardiocirculatory dysfunctions that typically and repeatedly occur during apnea episodes and also may persist during wakefulness. Regarding long-term factors, some changes in the anatomical characteristics of carotid arteries wall have been recognized in SDB patients. This finding seems to suggest that the link between SDB and cerebrovascular disease might be explained, at least in part, by an increase in the progression of the atherosclerosis process involving cerebral vessels. There are several practical implications from the demonstrated significant role of sleep apnea in increasing the predisposition to developing stroke. Specific investigation is fundamental in the presence of a clinical suspect of SDB, especially in patients with history of transient ischemic attacks and stroke. Specific treatment of SDB may reduce the possibility of further cerebrovascular disturbances.

Relationship quality and CPAP adherence in patients with obstructive sleep apnea

The prospective influence of relationship support and conflict on adherence to continuous positive airway pressure (CPAP) was examined over the first 3 months of CPAP treatment in 42 married, male patients with obstructive sleep apnea (OSA). CPAP adherence reports were available for 23 patients. Patient ratings of marital conflict predicted average nightly adherence (beta = -0.357, p < .05), but ratings of marital support did not predict adherence. Three-month follow-up ratings of marital support and conflict, subjective sleepiness, depression, and functional impairment were available for 16 patients from the first sample. Six additional patients without adherence reports provided baseline and 3-month follow-up questionnaire data, which resulted in a total of 22 patients with follow-up questionnaire data. Following 3 months of CPAP, patients reported decreased marital conflict (d = 0.43, p < .05), sleepiness (d = 1.13, p < .001), depression (d = 0.73, p < .001), and functional impairment (d = 1.48, p < .001). These findings highlight the importance of evaluating marital conflict for OSA patients and suggest marital conflict may be a target for interventions to improve CPAP adherence.

Prevalence and types of sleep disturbances acutely after traumatic brain injury

PRIMARY OBJECTIVE

To assess the prevalence of and risk factors for sleep disturbances in the acute post-traumatic brain injury (TBI) period.

RESEARCH DESIGN

Longitudinal, observational study.

METHODS AND PROCEDURES

Fifty-four first time closed-head injury patients were recruited and evaluated within 3 months after injury. Pre-injury and post-injury sleep disturbances were compared on the Medical Outcome Scale for Sleep. The subjects were also assessed on anxiety, depression, medical comorbidity and severity of TBI.

MAIN OUTCOMES AND RESULTS

Subjects were worse on most sleep measures after TBI compared to before TBI. Anxiety disorder secondary to TBI was the most consistent significant risk factor to be associated with worsening sleep status.

CONCLUSIONS

Anxiety is associated with sleep disturbances after TBI. Further studies need to be done to evaluate if this is a causal relationship.

[Anesthesia and sleep apnea syndrome]

The perioperative risk for patients with obstructive sleep apnea syndrome and the optimal anaesthesiological management of these patients have not been well elucidated. The prevalence of obstructive sleep apnea with significant symptoms is estimated to be 4% in men and 2% in women. However, in 80-95% of patients this syndrome is not sufficiently diagnosed. Thus identification of patients at risk and a thorough multidisciplinary diagnostic approach are essential for optimal perioperative management. The risk of perioperative complications, like cardiopulmonary compromise, and difficulties in airway management is elevated. The most important aspects of perioperative management include evaluation of intubating conditions, careful search for cardiopulmonary morbidity, permanent control of patient airways, sensible use of anaesthetics, sedatives, and narcotics, and strict monitoring of vital signs. If ambulatory nasal continuous positive airway pressure (CPAP) therapy has been established preoperatively, this should be continued in the perioperative period. Postoperative monitoring should be performed in an intensive care or intermediate care unit. Controlled clinical studies on the best perioperative management of patients with obstructive sleep apnea are urgently required.

Sleep-related breathing disorders in obese patients presenting with acute respiratory failure

INTRODUCTION

The study was conducted to assess the clinical and polysomnographic characteristics of patients with sleep-related breathing disorders who presented to the intensive care unit (ICU) with acute respiratory failure and the practicability of performing polysomnography for such patients.

MATERIAL AND METHODS

We analyzed clinical presentation, cause of admission to the ICU, ICU course and outcome of 11 subjects with acute respiratory failure who were diagnosed to have sleep disordered breathing based on polysomnography between October 1999 and January 2003. Subjects were compared to 11 patients with obstructive sleep apnea syndrome matched to each subject using body mass index, age and apnea hypopnea index measured at the time of diagnosis (matched comparison group). Repeated arterial blood gases and polysomnography were done for 8 subjects compliant to treatment 6-8 months after discharge from ICU.

RESULTS

The reason for ICU admission for all subjects was hypercapnic respiratory failure. pH and daytime PaO2 were significantly lower in studied subjects compared to the matched comparison group while awake daytime PaCO2 was significantly higher. Subjects had frequent episodes of hypoventilation. Follow up arterial blood gases and polysomnography 6-8 months after treatment (non-invasive ventilation) in compliant subjects showed significant improvement in all blood gases parameters.

CONCLUSIONS

Early polysomnography (or portable cardio-respiratory monitoring) allows accurate diagnosis and institution of the appropriate ventilation method Further studies should assess the evolution of respiratory drive in patients with sleep disordered breathing and hypercapnia under therapy (non-invasive ventilation).

The ineffectiveness of magnotherapy in a patient with obstructive sleep apnea syndrome and cardiovascular comorbidity

Obstructive sleep apnea syndrome (OSAS) is associated with mild to severe cardiovascular risks. The most common standard treatment for OSAS, continuous positive airway pressure, was found to have beneficial effects on cardiovascular sequelae of OSAS. Additionally, commercial companies promote nonprescription treatments for OSAS. These products frequently lack scientific support for their efficacy and need further research. We report an objective test of magnetic therapy, one such product, in a patient with OSAS and cardiovascular comorbidities. Two nights of polysomnographic recording using the split-night protocol did not reveal any consistent differences in OSAS symptoms whether the patient slept with or without the magnetic equipment. It was concluded that magnetic treatment was unsuccessful in reducing OSAS symptoms in our patient and may even increase possible cardiovascular and stroke risks by preventing the patient from pursuing an adequate medical treatment, such as continuous positive airway pressure.

Secondary prevention strategies in ischemic stroke: identification and optimal management of modifiable risk factors

The identification and treatment of modifiable Ischemic stroke risk factors, in addition to appropriate antithrombotic therapy, can reduce the likelihood of first or recurrent stroke, prevent long-term morbidity and mortality after first stroke or transient Ischemic attack, and lower health care costs. Long-term morbidity and mortality in patients with ischemic stroke includes patients with coronary artery disease. Therefore, in patients with ischemic stroke (especially those with carotid artery disease and lacunar disease), the goal is to prevent not only recurrent stroke but also coronary artery disease. Neurologists and general practitioners must be aware of the specific risk factors and recommendations for patients with ischemic stroke and apply the information systematically. We review known risk factors for ischemic stroke and current recommendations for treatment, focusing primarily on atherosclerotic risk factors as they apply to patients with stroke. In particular, recent data on hypertension and hyperlipidemia are described. In addition, we discuss the challenges in managing these risk factors and the potential strategies for overcoming them.

Sleep disorders in Alzheimer's disease and other dementias

Patients with dementias, such as Alzheimer's disease (AD), often have nocturnally disrupted sleep. Clinically, this may present as agitation during the nighttime hours, which may affect as many as a quarter of AD patients during some stage of their illness. Sleep disturbance in AD may be multifactorial and involve sleep-disordered breathing and disrupted chronobiology, both often characterized by excessive daytime napping. Polysomnographically, AD patients show decreased rapid eye movement (REM) sleep in proportion to the extent of their dementia; some evidence suggests that cholinesterase inhibitors, commonly used pharmacologic agents for cognitive loss in AD, may increase REM sleep measures. Unfortunately, such agents may also induce insomnia and vivid dreams. There have been no randomized clinical trials of sedative-hypnotic medications specifically targeted at AD patients with sleep problems. Evidence suggests that sedative-hypnotics, such as benzodiazepine site-specific agonists, may have a role in some cases, whereas atypical antipsychotics may be necessary in other cases. There are also reports of successful interventions with nonpharmacologic options (eg, exercise, illumination). The utility of melatonin as a hypnotic in this population appears equivocal.