High prevalence of sleep disorders and behavioral and psychological symptoms of dementia in late-onset Alzheimer disease: A study in Eastern China

The current status of apathy in patients with dementia and its factors: A systematic review

OBJECTIVE

To systematically evaluate the current status of apathy in dementia patients and its associated factors.

METHODS

We searched Chinese and English databases to collect studies on the associated factors of apathy in patients with dementia from inception to March 14, 2023. Two researchers independently screened the literature, evaluated the quality, and extracted the data RESULTS: A total of 20 studies were included, and the incidence of apathy in patients with dementia ranged from 21 % to 90 %. According to the model of apathy proposed by Massimo in 2018, the associated factors were divided into individual factors for dementia patients, caregiver factors, and environmental factors. The individual factors of apathy in patients with dementia mainly include demographic characteristics, the severity of cognitive impairment, a combination of other behavioral and psychological symptoms of dementia, acute medical problems or adverse drug reactions, unmet needs, and malnutrition. Caregiver factors mainly include emotional expressions of hostility or criticism towards dementia patients and caregivers' expectations for a better life in the future. Environmental factors mainly include too high or too low stimulation and a lack of daytime activities CONCLUSIONS: Existing studies have shown that the incidence of apathy in dementia patients is high and is affected by multi-dimensional factors. There are more studies on individual factors in dementia patients and fewer studies on caregivers and environmental factors. In the future, a large number of high-quality studies are needed to demonstrate the mechanism of apathy in dementia patients and to find more related factors.

Pharmacological interventions to improve sleep in people with Alzheimer's disease: a meta-analysis of randomized controlled trials

INTRODUCTION

This systematic review and meta-analysis evaluates the evidence from randomized controlled trials (RCTs) involving pharmacological interventions for improving sleep in people with Alzheimer's disease (AD).

METHODS

A systematic literature search in eight databases from January 2000 to July 2023 focusing on RCTs that compared a pharmacological intervention with a placebo for enhancing sleep in people with AD. The authors registered the study protocol at Prospero, followed the PRISMA guidelines, and produced the pooled estimates using random-effect or IVhet models.

RESULTS

Eight different interventions and 29 different sleep outcomes were examined in 14 RCTs included in this review. Eszopiclone positively affected sleep efficiency, as did orexin antagonists. However, there was no difference when melatonin was used. The interventions demonstrated low discontinuation rates and a few adverse drug reactions.

CONCLUSION

Although melatonin was the most investigated intervention, the evidence for its efficacy is inconclusive. On the other hand, trazodone and orexin receptor antagonists showed promising results; however, more RCTs are needed for definite answers.

Association among cognitive function, daytime activities, and nighttime sleep in older adults in a long-term care facility

AIM

To determine how the nighttime sleep patterns of older adults in a long-term care facility vary according to cognitive function and participation in daytime activities.

METHODS

This observational study was conducted with older adults aged ≥65 years who are residents of a long-term care facility. Nighttime sleep was monitored using a non-wearable sleep monitor for 8 weeks. Based on the Mini-Mental State Examination scores for assessment of cognitive function, participants were classified into non-dementia, mild-to-moderate dementia, and severe dementia groups. The Mann-Whitney U test and Kruskal-Wallis test were used to analyze the data.

RESULTS

Twenty three older adults were included in this study. Sleep onset latency was significantly longer in the severe dementia group than in the non-dementia (p = .027) and mild-to-moderate dementia (p = .041) groups. Sleep efficiency was significantly lower in the severe dementia group than in the mild-to-moderate dementia group (p = .003), whereas wakefulness after sleep onset was significantly longer in the severe dementia group than in the mild-to-moderate dementia group (p = .011). The number of days spent engaging in recreational activities was <50%, whereas those spent taking a nap was >60% in all older adults. Older adults with mild-to-moderate dementia had better sleep and participated in more daytime activities than those with severe or no dementia. Moreover, bathing in a bathtub improved sleep onset latency.

CONCLUSIONS

This study demonstrates that participation in daytime activities and bathing in a bathtub affect nighttime sleep in older adults.

Salivary Cortisol and Melatonin, Sleep, and Behavioral Patterns in Older Adults Living With Dementia

BACKGROUND

Over half of the older adults living with dementia have behavioral and psychological symptoms of dementia (BPSD), including sleep disturbance; however, little is known about physiological markers. Salivary cortisol and melatonin have been identified as potential biomarkers of BPSD, with evidence suggesting a relationship between these biomarkers and various behavioral factors, as well as sleep and activity patterns.

OBJECTIVES

The aim of this study was to investigate the time-dependent changes in salivary cortisol and melatonin levels in older adults with dementia, their relationship with the sleep-wake cycle, and their correlation with BPSD symptoms and behavioral factors.

METHODS

This observational study conducted in Seoul and Gyeonggi-do, South Korea, used data from 172 older adults with dementia, measuring sleep and activity patterns for 2 weeks using a wearable device, in addition to administering questionnaires for neuropsychiatric and psychological symptoms-the Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, and Cornell Scale for Depression in Dementia. Salivary cortisol and melatonin levels were measured at four time points and divided into four groups based on a dual-trajectory model. Differences among the groups were analyzed using one-way analysis of variance.

RESULTS

The participants showed normal but heterogeneous patterns of salivary cortisol and melatonin levels. Dual-trajectory pattern analysis showed that higher levels of melatonin during the daytime were correlated with poor nighttime sleep efficiency and decreased disinhibited behaviors, and higher levels of cortisol at all four time points were associated with decreased physical activity.

DISCUSSION

Measuring and analyzing periodic changes in cortisol and melatonin levels can predict various behavioral symptoms (e.g., sleep disturbances, activity counts, and disinhibition) in older adults with dementia. A study with an experimental design is needed to discover the direct physiological interactions between cortisol, melatonin, and these symptoms.

Prevalence and Risk of Behavioral Symptoms among Patients with Insomnia and Alzheimer's Disease: A Retrospective Database Analysis

OBJECTIVES

This study evaluated the prevalence and patterns of behavioral symptoms, including agitation/aggression (AA), psychotic symptoms (PS), anxiety/mood disorders (MD), and delirium among patients with Alzheimer's disease (AD) and their association with diagnosed insomnia.

DESIGN

A retrospective cohort analysis was conducted using the MarketScan Multi-State Medicaid Database 2016-2020.

SETTING AND PARTICIPANTS

Patients aged ≥50 with newly diagnosed AD (N = 56,904) were identified during 2017-2019 and categorized into insomnia and non-insomnia groups based on billing codes recorded in medical and pharmacy claims.

METHODS

The index date was defined as the earliest date of diagnosis/medication of insomnia. The new diagnosis of AD had to be established within 12 months before (baseline) or 3 months after the index date. Point prevalence of behavioral symptoms was estimated during baseline and the 12-month follow-up period. Propensity score matching was performed to match patients with and without insomnia. Multivariable conditional logistic regression was used to assess the risk of diagnosis of behavioral symptoms among insomnia and non-insomnia groups.

RESULTS

The study cohort included 7808 patients with newly diagnosed AD (mean age = 79.4, SD = 9.6 years). The point prevalence of behavioral symptoms was as follows: among those with insomnia (n = 3904), in the baseline, AA = 9.0%, PS = 12.5%, and MD = 57.8%, and during the follow-up, AA = 13.9%, PS = 16.3%, and MD = 72.1%; among those without insomnia (n = 3904), in the baseline, AA = 6.2%, PS = 9.2%, and MD = 41.4%; and during the follow-up, AA = 7.4%, PS = 10.4%, and MD = 49.2%. The likelihood of being diagnosed with any behavioral symptoms in the follow-up period was significantly higher among patients with insomnia than those without [adjusted odds ratio (OR), 2.7; 95% confidence interval (CI), 2.4-3.1].

CONCLUSIONS AND IMPLICATIONS

In patients with AD, prevalence of behavioral symptoms and likelihood of being diagnosed with behavioral symptoms were significantly higher among patients with diagnosed insomnia. Further investigation is needed to understand the relationship between insomnia and behavioral symptoms in patients with AD.

Comparing clinico-demographics and neuropsychiatric symptoms for immigrant and non-immigrant aged care residents living with dementia: a retrospective cross-sectional study from an Australian dementia-specific support service

BACKGROUND

Neuropsychiatric symptoms of dementia such as agitation and aggression are common in people living with dementia. The presentation of neuropsychiatric symptoms is influenced by the cultural background of people living with dementia. Further, identifying factors contributing to neuropsychiatric symptoms may be complicated if people living with dementia are immigrants or from non-English-speaking backgrounds. Most of what is known about differences in neuropsychiatric symptoms between racial and ethnic groups living with dementia come from community-based samples. This study investigated differences in clinico-demographics and neuropsychiatric symptoms between immigrants and non-immigrants living with dementia in residential aged care homes who were referred to two Dementia Support Australia programs.

METHODS

This was a retrospective observational cross-sectional study from 2018 to 2022 using data extracted from the Dementia Support Australia database. Immigrant status was identified by documented country of birth. We conducted exploratory subgroup analyses for English-speaking or non-English-speaking immigrants in comparison to non-immigrants. Neuropsychiatric Inventory and PainChek® were used to assess neuropsychiatric symptoms of dementia and pain, respectively.

RESULTS

Of the 23,889 referrals, 36% were immigrants living with dementia. Immigrants were 0.8 years older than non-immigrants on average. Immigrants had a slightly higher prevalence of mixed dementia (9.5%) than non-immigrants (8.2%). Overall, the groups had no difference in the severity of neuropsychiatric symptoms and associated caregiver distress. However, there was a significant difference in the total number of neuropsychiatric inventory domains (Cohen's d = -0.06 [-0.09, - 0.02], p <.001) between non-English-speaking immigrants and non-immigrants. Immigrants were more likely to present with agitation/aggression, while non-immigrants were more likely to present with hallucinations. Factors contributing to neuropsychiatric symptoms were common between the groups, with language barriers and cultural considerations frequently endorsed for immigrants.

CONCLUSION

This study reveals a mixed picture of neuropsychiatric symptoms between immigrants and non-immigrants. However, due to the exploratory nature of the hypotheses, our findings need to be replicated in future studies to confirm any conclusions. There is a need for increased awareness on the impact of culture and language on neuropsychiatric symptoms for people receiving residential care. Future studies investigating neuropsychiatric symptoms in different immigrant groups will help increase our understanding of neuropsychiatric symptoms for all people.

The effectiveness of a therapeutic robot, 'Paro', on behavioural and psychological symptoms, medication use, total sleep time and sociability in older adults with dementia: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of a therapeutic robot, 'Paro', on anxiety, agitation, depression, apathy, medication use, total sleep time, and sociability among older adults with dementia.

DESIGN

Systematic review and meta-analysis with narrative synthesis.

SETTING AND PARTICIPANTS

Older adults aged 60 years and above with any form of dementia in the community, nursing homes, or care facilities.

METHODS

A three-step search strategy was conducted by two independent reviewers. Nine databases were searched (January 2003 to November 2022). Randomised controlled, crossover, and cluster trials on Paro for older adults with dementia published in English were included. All relevant trials were screened and assessed for risk of bias. Data were extracted using the Cochrane data collection form. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence.

RESULTS

In total, 12 articles involving 1461 participants were included. Results of the meta-analysis showed that Paro had a moderate effect on medication use (SMD: -0.63) and small effect on anxiety (SMD: -0.17), agitation (SMD: -0.27) and depression (SMD: -0.40). However, Paro exhibited negligible effect on total sleep time (SMD: -0.12). The overall quality of evidence for all outcomes were graded as low due to methodological limitations, small sample size, and wide confidence intervals. Narrative synthesis suggested that Paro reduced apathy and increase sociability.

CONCLUSION AND IMPLICATIONS

Paro could be a beneficial non-pharmacological approach to improve behavioural and psychological symptoms of dementia, reducing medication use, and increasing sociability for older adults with dementia. However, the results should be interpreted with caution as limited studies were available. Additionally, there were a variety of approaches across the studies (i.e. group and individual interventions, facilitated and non-facilitated) which made it difficult to determine which interventional approach is optimal to produce beneficial effects of Paro. Hence, more rigorous studies with a larger sample size are needed to fully understand the mechanism and effectiveness of Paro in older adults with dementia. The protocol was registered on PROSPERO (CRD42022296504).

Efficacy of Blue LED Phototherapy on Sleep Quality and Behavioral and Psychological Symptoms of Dementia: A Double-Blind Randomized Controlled Trial

INTRODUCTION

People with dementia often experience behavioral and psychological symptoms of dementia (BPSD), which are a major cause of caregiver burden and institutionalization. Therefore, we conducted a double-blind, parallel-group randomized controlled trial to examine the efficacy of blue-enriched light therapy for BPSD in institutionalized older adults with dementia.

METHODS

Participants were enrolled and randomly allocated into blue-enriched light therapy (N = 30) or the conventional light group (N = 30) for 60 min in 10 weeks with five sessions per week. The primary outcome was sleep quality measured by actigraphy and Pittsburgh Sleep Quality Index (PSQI). The secondary outcome was overall BPSD severity (Cohen-Mansfield Agitation Inventory [CMAI] and Neuropsychiatric Inventory [NPI-NH]). The outcome indicators were assessed at baseline, mid-test, immediate posttest, 1-month, 3-month, and 6-month follow-up. The effects of the blue-enriched light therapy were examined by the generalized estimating equation model.

RESULTS

Blue-enriched light therapy revealed significant differences in the objective sleep parameters (sleep efficiency: β = 5.81, Waldχ2 = 32.60, CI: 3.82; 7.80; sleep latency: β = -19.82, Waldχ2 = 38.38, CI:-26.09; -13.55), subjective sleep quality (PSQI: β = -2.07, Waldχ2 = 45.94, CI: -2.66; -1.47), and overall BPSD severity (CMAI: β = -0.90, Waldχ2 = 14.38, CI: -1.37; -0.44) (NPI-NH: β = -1.67, Waldχ2 = 30.61, CI: -2.26; -1.08) compared to conventional phototherapy immediate posttest, 1-month, 3-month, and 6-month follow-up. Furthermore, the effects for sleep efficiency and sleep latency lasted for up to 6 months. In the subscale analysis, the differences of the behavioral symptoms changed significantly between the groups in physical/nonaggressive (CI: -1.01; -0.26) and verbal/nonaggressive (CI: -0.97; -0.29).

CONCLUSIONS

Blue-enriched light therapy is a feasible low-cost intervention that could be integrated as a comprehensive therapy program for BPSD among older adults with dementia.

The relationships between physical function, nutrition, cognitive function, depression, and sleep quality for facility-dwelling older adults with dynapenia

BACKGROUND

The growing population of older adults worldwide is associated with an extended life expectancy and an increasing proportion of older adults with dynapenia. Most research on dynapenia has involved only populations of older adults living in the community; little research has examined the effects of risk factors on sleep quality among older adults with dynapenia residing in assisted living facilities.

AIM

This study examined the relationships among physical function, nutrition, cognitive function, depression, and sleep quality among older adults with dynapenia residing in assisted living facilities.

METHODS

In this cross-sectional study, data on physical function, nutrition, cognitive function, depression, and sleep quality was collected from 178 older adults with dynapenia residing in assisted living facilities, who were selected using purposive sampling. Descriptive statistical analysis, independent-sample t tests, chi-squared tests, and logistic regression analysis were performed using SPSS 25.0.

RESULTS

The statistical analyses revealed correlations between sleep quality and age (t = 2.37, p < 0.05), level of education (χ2 = 3.85, p < 0.05), grip strength (t = 3.40, p < 0.01), activities of daily living (t = 4.29, p < 0.001), instrumental activities of daily living (t = 2.23, p < 0.001), calf circumference (t = 2.89, p < 0.01), Mini Nutritional Assessment scores (t = 2.29, p < 0.05), Mini Mental State Exam (MMSE) scores (t = 4.50, p < 0.001), and Geriatric Depression Scale (GDS) scores (t = - 4.20, p < 0.001). Calf circumference (OR = 0.8, 95% CI = 0.650.97, p < 0.05), GDS score (OR = 1.42, 95% CI = 1.05-1.92, p < 0.05), and MMSE score (OR = 0.85, 95% CI = 0.73-0.97, p < 0.05) were related to sleep quality among the sample population.

CONCLUSION

Physical function, nutrition, cognitive function, and depression affect the sleep quality of older adults with dynapenia residing in assisted living facilities. Facility nurses must regularly assess these aspects of their patients to ensure that facility-dwelling older adults can maintain their physical function and improve their health to improve the quality of their sleep.

Relationship between APOE, PER2, PER3 and OX2R Genetic Variants and Neuropsychiatric Symptoms in Patients with Alzheimer's Disease

Alzheimer's disease (AD) is characterized by the presence of neuropsychiatric or behavioral and psychological symptoms of dementia (BPSD). BPSD have been associated with the APOE_ε4 allele, which is also the major genetic AD risk factor. Although the involvement of some circadian genes and orexin receptors in sleep and behavioral disorders has been studied in some psychiatric pathologies, including AD, there are no studies considering gene-gene interactions. The associations of one variant in PER2, two in PER3, two in OX2R and two in APOE were evaluated in 31 AD patients and 31 cognitively healthy subjects. Genotyping was performed using real-time PCR and capillary electrophoresis from blood samples. The allelic-genotypic frequencies of variants were calculated for the sample study. We explored associations between allelic variants with BPSD in AD patients based on the NPI, PHQ-9 and sleeping disorders questionnaires. Our results showed that the APOE_ε4 allele is an AD risk variant (p = 0.03). The remaining genetic variants did not reveal significant differences between patients and controls. The PER3_rs228697 variant showed a nine-fold increased risk for circadian rhythm sleep-wake disorders in Mexican AD patients, and our gene-gene interaction analysis identified a novel interaction between PERIOD and APOE gene variants. These findings need to be further confirmed in larger samples.

Poor Sleep Quality in Aging: The Association with Mental Health

Sleep disturbances are common in the elderly. A primary sleep disorder can result from the physiological decline of aging; however, secondary sleep problems result from various causes involving physical and mental health. Since little is known about the relationships between sleep quality and mental health in aging, the present study aims to understand how different aspects generally associated with sleep (e.g., psychological and physiological factors, and sleep medication) may predict poor sleep quality in different stages of the lifespan. Therefore, we conducted several analyses (ANOVAs, Pearson correlations, and linear regressions) to test the hypotheses of the study. Accordingly, from a pool of 180 participants (elderly, middle-aged, and young adults), 143 individuals with poor sleep quality were selected. Different predictive patterns in the three groups emerged. Specifically, the use of sleep medication associated with worse sleep conditions is predicted by poor sleep quality in the elderly and by depression in young adults. In contrast, worsening sleep quality is predicted by depression in middle-aged adults. Previous studies focused on the transitions from good to poor sleep quality, while this is the first study to have examined the features of poor sleep quality in aging, highlighting different sleep patterns across the lifespan. This evidence should be considered from a preventive perspective.

The gut microbiome and Alzheimer's disease: Complex and bidirectional interactions

Structural and functional alterations to the gut microbiome, referred to as gut dysbiosis, have emerged as potential key mediators of neurodegeneration and Alzheimer disease (AD) pathogenesis through the "gut -brain" axis. Emerging data from animal and clinical studies support an important role for gut dysbiosis in mediating neuroinflammation, central and peripheral immune dysregulation, abnormal brain protein aggregation, and impaired intestinal and brain barrier permeability, leading to neuronal loss and cognitive impairment. Gut dysbiosis has also been shown to directly influence various mechanisms involved in neuronal growth and repair, synaptic plasticity, and memory and learning functions. Aging and lifestyle factors including diet, exercise, sleep, and stress influence AD risk through gut dysbiosis. Furthermore, AD is associated with characteristic gut microbial signatures which offer value as potential markers of disease severity and progression. Together, these findings suggest the presence of a complex bidirectional relationship between AD and the gut microbiome and highlight the utility of gut modulation strategies as potential preventative or therapeutic strategies in AD. We here review the current literature regarding the role of the gut-brain axis in AD pathogenesis and its potential role as a future therapeutic target in AD treatment and/or prevention.

Sleep Quality and Aging: A Systematic Review on Healthy Older People, Mild Cognitive Impairment and Alzheimer’s Disease

Aging is characterized by changes in the structure and quality of sleep. When the alterations in sleep become substantial, they can generate or accelerate cognitive decline, even in the absence of overt pathology. In fact, impaired sleep represents one of the earliest symptoms of Alzheimer’s disease (AD). This systematic review aimed to analyze the studies on sleep quality in aging, also considering mild cognitive impairment (MCI) and AD. The review process was conducted according to the PRISMA statement. A total of 71 studies were included, and the whole sample had a mean age that ranged from 58.3 to 93.7 years (62.8–93.7 healthy participants and 61.8–86.7 pathological populations). Of these selected studies, 33 adopt subjective measurements, 31 adopt objective measures, and 10 studies used both. Pathological aging showed a worse impoverishment of sleep than older adults, in both subjective and objective measurements. The most common aspect compromised in AD and MCI were REM sleep, sleep efficiency, sleep latency, and sleep duration. These results underline that sleep alterations are associated with cognitive impairment. In conclusion, the frequency and severity of sleep disturbance appear to follow the evolution of cognitive impairment. The overall results of objective measures seem more consistent than those highlighted by subjective measurements.

Factors Associated With Sleep Quality in Hospitalized Persons With Dementia

BACKGROUND

Factors associated with sleep quality have not been well examined in hospitalized older persons with dementia, who are at high risk for impaired sleep. The aim was to identify factors associated with sleep quality among hospitalized persons with dementia.

METHODS

This secondary analysis used baseline data from a cluster randomized trial. Factors examined included delirium severity, pain, depression, behavioral and psychological symptoms of dementia (BPSD), and daytime physical activity. Multiple stepwise linear regressions evaluated factors related to dimensions of sleep quality (sleep duration, efficiency, latency, and fragmentation; measured by the MotionWatch 8).

RESULTS

Increased daytime physical activity was associated with higher sleep duration [β=0.164; 95% confidence interval (CI), 0.111-0.717; P=0.008; 7.7% variance] and sleep efficiency (β=0.158; 95% CI, 0.020-0.147; P=0.010; 5.4% variance), and less sleep fragmentation (β=-0.223; 95% CI, -0.251 to -0.077; P<0.001; 10.4% variance). Higher BPSD was significantly associated with prolonged sleep latency (β=0.130; 95% CI, 0.098-2.748; P=0.035; 3.7% variance).

CONCLUSION

Results suggest the need to encourage daytime physical activity and reduce or manage BPSD to improve sleep quality among hospitalized persons with dementia.

Progress in the correlation of postoperative cognitive dysfunction and Alzheimer's disease and the potential therapeutic drug exploration

Postoperative cognitive dysfunction (POCD) is a decrease in mental capacity that can occur days to weeks after a medical procedure and may become permanent and rarely lasts for a longer period of time. With the continuous development of research, various viewpoints in academic circles have undergone subtle changes, and the role of anesthesia depth and anesthesia type seems to be gradually weakened; Alzheimer's disease (AD) is a latent and progressive neurodegenerative disease in the elderly. The protein hypothesis and the synaptic hypothesis are well-known reasons. These changes will also lead to the occurrence of an inflammatory cascade. The exact etiology and pathogenesis need to be studied. The reasonable biological mechanism affecting brain protein deposition, neuroinflammation, and acetylcholine-like effect has a certain relationship between AD and POCD. Whereas there is still further uncertainty about the mechanism and treatment, and it is elusive whether POCD is a link in the continuous progress of AD or a separate entity, which has doubts about the diagnosis and treatment of the disease. Therefore, this review is based on the current common clinical characteristics of AD and POCD, and pathophysiological research, to search for their common points and explore the direction and new strategies for future treatment.

Burden of Insomnia and Sleep Disturbances and the Impact of Sleep Treatments in Patients with Probable or Possible Alzheimer's Disease: A Structured Literature Review

Background:

Sleep disturbances are frequent in Alzheimer’s disease (AD).

Objective:

To summarize the impact of sleep disturbances on AD patients and their caregivers and the effects of currently available sleep therapies.

Methods:

Published studies (January 1985–March 2020) assessing the burden associated with insomnia/sleep disturbances in the AD population and insomnia treatment effects were identified by searching PubMed, Embase, and Cochrane Library and screened against inclusion criteria.

Results:

58 studies assessing patient and caregiver burden, institutionalization, and insomnia treatments in AD patients with sleep disturbances were identified. Sleep disturbances were associated with worse cognition, functional ability, and behavioral and neuropsychological functioning. Health status and quality of life of both patients and caregivers were reduced in the presence of sleep disturbances. Sleep disturbances were also associated with institutionalization. Although significant associations between sleep problems and clinical outcomes were apparent, there was generally no control for other influencing factors (e.g., cognitive status). Bright light and behavioral therapies as well as drugs showed some promise in AD patients, but studies were primarily small and limited data were available, particularly in regard to the effect on associated clinical burden.

Conclusion:

Sleep disturbances are a significant problem for AD patients and caregivers, associated with behavioral and psychological problems and cognitive decline. However, they remain poorly characterized and under-researched. As the global population is aging and AD is on thes rise, data from larger, prospective trials are required to fully understand the clinical correlates of sleep disturbances and the impact insomnia treatments can have.

What evidence is there for implicating the brain orexin system in neuropsychiatric symptoms in dementia?

Neuropsychiatric symptoms (NPS) affect people with dementia (PwD) almost universally across all stages of the disease, and regardless of its exact etiology. NPS lead to disability and reduced quality of life of PwD and their caregivers. NPS include hyperactivity (agitation and irritability), affective problems (anxiety and depression), psychosis (delusions and hallucinations), apathy, and sleep disturbances. Preclinical studies have shown that the orexin neuropeptide system modulates arousal and a wide range of behaviors via a network of axons projecting from the hypothalamus throughout almost the entire brain to multiple, even distant, regions. Orexin neurons integrate different types of incoming information (e.g., metabolic, circadian, sensory, emotional) and convert them into the required behavioral output coupled to the necessary arousal status. Here we present an overview of the behavioral domains influenced by the orexin system that may be relevant for the expression of some critical NPS in PwD. We also hypothesize on the potential effects of pharmacological interference with the orexin system in the context of NPS in PwD.

Vegetable and Fruit Intake, Its Patterns, and Cognitive Function: Cross-Sectional Findings among Older Adults in Anhui, China

OBJECTIVES

To examine the associations of vegetable and fruit intake frequency, its patterns, and cognition among older Chinese adults.

DESIGN

Cross-sectional data obtained from the Anhui Province Healthy Longevity Survey.

SETTING

Urban and rural communities.

PARTICIPANTS

A total of 5410 older adults (aged 60 or older) were included from selected communities.

MEASUREMENTS

Data on the number of days in a typical week that vegetables and fruits were consumed were collected, and the four intake patterns were defined (V+/F+: daily intake of both vegetables and fruit; V+/F- or V-/F+: daily intake of vegetables or fruit; and V-/F-: no daily intake of either vegetables or fruit). Cognitive function was measured using the Mini-mental State Examination (MMSE), and mild cognitive impairment (MCI) was defined according to education-specific criteria.

RESULTS

Nondaily vegetable intake was associated with lower MMSE scores (β = -0.763, 95% confidence interval (CI): -1.463, -0.064) among males and a higher likelihood of having MCI (OR: 1.409, 95% CI: 1.037, 1.915) among females. Less frequent intake of fruit was associated with lower MMSE scores and a higher prevalence of MCI among both males and females (p for trends < 0.001 for both sexes). Compared with the V+/F+ group, male participants who were classified into the V+/F- and V-/F- groups had lower MMSE scores (V+/F-: β = -0.612, 95% CI: -1.094, -0.131; V-/F-: β = -1.273, 95% CI: -2.090, -0.455). Females classified in the V+/F- and V-/F- patterns had lower MMSE scores (V+/F-: β = -0.862, 95% CI: -1.320, -0.404; V-/F-: β = -1.293, 95% CI: -2.079, -0.507) and elevated risks of MCI (V+/F-: OR: 1.762, 95% CI: 1.386, 2.242; V-/F-: OR: 2.180, 95% CI: 1.505, 3.156).

CONCLUSION

Lower vegetable or fruit intake was associated with poorer cognitive performance among males and females, and the risk was even higher among those with a low intake of both vegetables and fruits. Healthy eating habits, including daily vegetable and fruit intake, are essential for cognition maintenance in both males and females.

Sleep Quality Improvement Enhances Neuropsychological Recovery and Reduces Blood Aβ42/40 Ratio in Patients with Mild–Moderate Cognitive Impairment

Background and objectives: Alzheimer’s disease is a progressive brain degeneration and is associated with a high prevalence of sleep disorders. Amyloid β peptide-42/40 (Aβ_42/40) and Tau-pT181 are the core biomarkers in cerebrospinal fluid and blood. Accumulated data from studies in mouse models and humans demonstrated an aberrant elevation of these biomarkers due to sleep disturbance, especially sleep-disordered breathing (SDB). However, it is not clear if sleep quality improvement reduces the blood levels of Ab_42/40 ratio and Tau-pT181 in Alzheimer’s disease patients. Materials and Methods: In this prospective study, a longitudinal analysis was conducted on 64 patients with mild–moderate cognition impairment (MCI) due to Alzheimer’s disease accompanied by SDB. Another 33 MCI cases without sleep-disordered breathing were included as the control group. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) score system. Neuropsychological assessments were conducted using the Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale (GDS), Clinical Dementia Rating (CDR), 24-h Hamilton Rating Scale for Depression (HRSD-24), and Hamilton Anxiety Rating Scale (HAMA) scoring systems. Aβ₄₂, Aβ_40, and Tau-pT181 protein levels in blood specimens were measured using ELISA assays. All patients received donepezil treatment for Alzheimer’s disease. SDB was managed with continuous pressure ventilation. Results: A significant correlation was found among PSQI, HRSD-24, HAMA, Aβ_42/40 ratio, and Tau-pT181 level in all cases. In addition, a very strong and negative correlation was discovered between education level and dementia onset age. Compared to patients without SDB (33 non-SD cases), patients with SDB (64 SD cases) showed a significantly lower HRSD-24 score and a higher Aβ_42/40 ratio Tau-pT181 level. Sleep treatment for patients with SDB significantly improved all neuropsychological scores, Aβ_42/40 ratio, and Tau-pT181 levels. However, 11 patients did not completely recover from a sleep disorder (PSQI > 5 post-treatment). In this subgroup of patients, although HAMA score and Tau-pT181 levels were significantly reduced, MoCA and HRSD-24 scores, as well as Aβ_42/40 ratio, were not significantly improved. ROC analysis found that the blood Aβ_42/40 ratio held the highest significance in predicting sleep disorder occurrence. Conclusions: This is the first clinical study on sleep quality improvement in Alzheimer’s disease patients. Sleep quality score was associated with patient depression and anxiety scores, as well as Aβ_42/40 ratio and Tau-pT181 levels. A complete recovery is critical for fully improving all neuropsychological assessments, Aβ_42/40 ratio, and Tau-pT181 levels. Blood Aβ_42/40 ratio is a feasible prognostic factor for predicting sleep quality.

Factors Associated With Behavioral and Psychological Symptoms of Dementia: Prospective Observational Study Using Actigraphy

BACKGROUND

Although disclosing the predictors of different behavioral and psychological symptoms of dementia (BPSD) is the first step in developing person-centered interventions, current understanding is limited, as it considers BPSD as a homogenous construct. This fails to account for their heterogeneity and hinders development of interventions that address the underlying causes of the target BPSD subsyndromes. Moreover, understanding the influence of proximal factors-circadian rhythm-related factors (ie, sleep and activity levels) and physical and psychosocial unmet needs states-on BPSD subsyndromes is limited, due to the challenges of obtaining objective and/or continuous time-varying measures.

OBJECTIVE

The aim of this study was to explore factors associated with BPSD subsyndromes among community-dwelling older adults with dementia, considering sets of background and proximal factors (ie, actigraphy-measured sleep and physical activity levels and diary-based caregiver-perceived symptom triggers), guided by the need-driven dementia-compromised behavior model.

METHODS

A prospective observational study design was employed. Study participants included 145 older adults with dementia living at home. The mean age at baseline was 81.2 (SD 6.01) years and the sample consisted of 86 (59.3%) women. BPSD were measured with a BPSD diary kept by caregivers and were categorized into seven subsyndromes. Independent variables consisted of background characteristics and proximal factors (ie, sleep and physical activity levels measured using actigraphy and caregiver-reported contributing factors assessed using a BPSD diary). Generalized linear mixed models (GLMMs) were used to examine the factors that predicted the occurrence of BPSD subsyndromes. We compared the models based on the Akaike information criterion, the Bayesian information criterion, and likelihood ratio testing.

RESULTS

Compared to the GLMMs with only background factors, the addition of actigraphy and diary-based data improved model fit for every BPSD subsyndrome. The number of hours of nighttime sleep was a predictor of the next day's sleep and nighttime behaviors (odds ratio [OR] 0.9, 95% CI 0.8-1.0; P=.005), and the amount of energy expenditure was a predictor for euphoria or elation (OR 0.02, 95% CI 0.0-0.5; P=.02). All subsyndromes, except for euphoria or elation, were significantly associated with hunger or thirst and urination or bowel movements, and all BPSD subsyndromes showed an association with environmental change. Age, marital status, premorbid personality, and taking sedatives were predictors of specific BPSD subsyndromes.

CONCLUSIONS

BPSD are clinically heterogeneous, and their occurrence can be predicted by different contributing factors. Our results for various BPSD suggest a critical window for timely intervention and care planning. Findings from this study will help devise symptom-targeted and individualized interventions to prevent and manage BPSD and facilitate personalized dementia care.

Sensory-Evoked 40-Hz Gamma Oscillation Improves Sleep and Daily Living Activities in Alzheimer's Disease Patients

Pathological proteins contributing to Alzheimer’s disease (AD) are known to disrupt normal neuronal functions in the brain, leading to unbalanced neuronal excitatory-inhibitory tone, distorted neuronal synchrony, and network oscillations. However, it has been proposed that abnormalities in neuronal activity directly contribute to the pathogenesis of the disease, and in fact it has been demonstrated that induction of synchronized 40 Hz gamma oscillation of neuronal networks by sensory stimulation reverses AD-related pathological markers in transgenic mice carrying AD-related human pathological genes. Based on these findings, the current study evaluated whether non-invasive sensory stimulation inducing cortical 40 Hz gamma oscillation is clinically beneficial for AD patients. Patients with mild to moderate AD (n = 22) were randomized to active treatment group (n = 14; gamma sensory stimulation therapy) or to sham group (n = 8). Participants in the active treatment group received precisely timed, 40 Hz visual and auditory stimulations during eye-closed condition to induce cortical 40 Hz steady-state oscillations in 1-h daily sessions over a 6-month period. Participants in the sham group were exposed to similar sensory stimulation designed to not evoke cortical 40 Hz steady-state oscillations that are observed in the active treatment patients. During the trial, nighttime activities of the patients were monitored with continuous actigraphy recordings, and their functional abilities were measured by Alzheimer’s Disease Cooperative Study – Activities of Daily Living (ADCS-ADL) scale. Results of this study demonstrated that 1-h daily therapy was well tolerated throughout the 6-month treatment period by all subjects. Patients receiving gamma sensory stimulation showed significantly reduced nighttime active periods, in contrast, to deterioration in sleep quality in sham group patients. Patients in the sham group also showed the expected, significant decline in ADCS-ADL scores, whereas patients in the gamma sensory stimulation group fully maintained their functional abilities over the 6-month period. These findings confirm the safe application of 40 Hz sensory stimulation in AD patients and demonstrate a high adherence to daily treatment. Furthermore, this is the first time that beneficial clinical effects of the therapy are reported, justifying expanded and longer trials to explore additional clinical benefits and disease-modifying properties of gamma sensory stimulation therapy.

Clinical Trial Registration:clinicaltrials.gov, identifier: NCT03556280.

Clinical Decision-Making: Restless Legs Syndrome and Dementia in Older Adults

Restless legs syndrome (RLS), one of the more prevalent sleep disturbances among older adults, impacts quality of life. Patients with dementia are at high risk for developing RLS and may be unable to describe their symptoms. Often underdiagnosed, RLS can contribute to discomfort, pain, nighttime agitation, disturbed sleep, and falls. Clinical assessment is crucial and should include a thorough evaluation with input from the patient and family, deprescribing medication if possible, and consideration of common sleep-disturbing factors. Evidence-based treatment in this population is limited; overall focus should center on relieving discomfort while identifying and treating bothersome sleep symptoms.

Altered intrinsic brain activity in mild Alzheimer's disease patients with sleep disturbances

Sleep disturbances are one of the preventive factors to delay the onset and progression of Alzheimer's disease. Early identification of Alzheimer's disease patients prone to develop sleep disturbances to offer early medical intervention is important. Resting-state functional MRI is a widely used method to investigate the neural mechanisms and find neuroimaging biomarkers in neuropsychiatric diseases. In this study, we applied percent amplitude of fluctuation (PerAF) and mPerAF (divided by global mean PerAF) to test the strength of intrinsic brain activity in 38 mild Alzheimer's disease patients with sleep disturbances (ADSD) and 21 mild Alzheimer's disease patients without sleep disturbances (ADNSD). Compared with ADNSD, we found decreased intrinsic brain activity in the calcarine gyrus, the lingual gyrus, the fusiform gyrus extending to the parahippocampal gyrus, the precentral gyrus, the postcentral gyrus (all in the left hemisphere) and the left brainstem. Conclusively, ADSD exhibited reduced neural activity in specific brain regions related to the sensorimotor network and the visual network, which indicated the contribution of sleep disturbances to the progression of Alzheimer's disease. Especially, the ventral visual pathway to the hippocampus might serve for the memory impaired by sleep disturbances in Alzheimer's disease, and the brainstem might be critical in the initiation of sleep disturbances in Alzheimer's disease. These findings further elucidate the interactions between Alzheimer's disease and sleep disturbances and could help with the early recognition of Alzheimer's disease patients who tend to develop sleep disturbances.

Assessment of sleep quality and its predictors among newly diagnosed psychiatric patients

OBJECTIVES

Poor sleep is a vital symptom observed in many psychiatric conditions and is the most neglected and underdiagnosed. The current study aims at assessment of sleep quality among psychiatric patients using the Pittsburgh Sleep Quality Index (PSQI) scale and to identify the predictors of sleep quality.

METHODS

A hospital-based cross-sectional observational study conducted in the Psychiatry department with a sample size of 256 patients for six months. PSQI scale was used to assess sleep quality and multiple logistic regression was used (to identify) the predictors for poor sleep quality.

RESULTS

The mean age of the study population was 37.95 ± 14.11 years, with 148 (58%) male study participants. 192 (75%) of the study population had poor sleep quality with respect to PSQI scale with a mean score of 9.05 ± 4.65 that was well above the expected range (0-5) suggestive of compromised quality of sleep (p=0.001). Poor sleep satisfaction, waking up after the sleep onset, anorexia, day time drowsiness and at least one completely sleepless night in the past one week of admission were identified as good predictors for poor sleep quality.

CONCLUSIONS

Our study addresses the importance of assessing sleep quality regardless of the psychiatric conditions. We recommend screening patients if they have Poor sleep satisfaction, waking up after the sleep onset, anorexia, day time drowsiness or at least one completely sleepless night in the past one week of admission predictors for comorbid sleep disorders.

Insomnia as a predictor of diagnosed memory problems: 2006-2016 Health and Retirement Study

OBJECTIVE

To evaluate the longitudinal relationship in insomnia symptoms over time with incident memory problems and dementia diagnoses among U.S. adults aged 65 years and older.

METHODS

Secondary analyses were performed on 9518 elderly participants (≥65 years) who completed the 2006 wave of the Health and Retirement Study (HRS) and were followed-up to determine if insomnia symptom scores (2006-2014) were associated with time-to-onset of [1] physician-diagnosed "memory-related disease", "Alzheimer's disease" and/or "dementia, senility or any other serious memory impairment" and [2] diagnosis of dementia based on HRS-specific criteria. Cox proportional hazards models were constructed adjusting for socio-demographic, lifestyle, and health characteristics.

RESULTS

In fully adjusted models, severe insomnia symptoms were associated with increased risk of physician-diagnosed memory problems. Individuals reporting any change (increase or decrease) in insomnia symptoms during the 2006-2010 period were more likely to be diagnosed with dementia based on HRS criteria. Finally, those who experienced an increase in the severity of insomnia symptoms over time exhibited 41-72% increased risks of physician-diagnosed memory problems and 45-58% increased risks of dementia diagnosis based on HRS criteria.

CONCLUSIONS

When severe insomnia symptoms increased over time, physician-diagnosed memory problems and dementia diagnoses also increased among U.S. elderly people over a 10-year follow-up period. More studies are required to confirm these findings using large prospective cohort designs and validated tools.

Study Protocol on the Validation of the Quality of Sleep Data from Xiaomi Domestic Wristbands

(1) Background: Sleep disorders are a common problem for public health since they are considered potential triggers and predictors of some mental and physical diseases. Evaluating the sleep quality of a person may be a first step to prevent further health issues that diminish their independence and quality of life. Polysomnography (PSG) is the “gold standard” for sleep studies, but this technique presents some drawbacks. Thus, this study intends to assess the capability of the new Xiaomi Mi Smart Band 5 to be used as a tool for sleep self-assessment. (2) Methods: This study will be an observational and prospective study set at the sleep unit of a hospital in A Coruña, Spain. Forty-three participants who meet the inclusion criteria will be asked to participate. Specific statistical methods will be used to analyze the data collected using the Xiaomi Mi Smart Band 5 and PSG. (3) Discussion: This study offers a promising approach to assess whether the Xiaomi Mi Smart Band 5 correctly records our sleep. Even though these devices are not expected to replace PSG, they may be used as an initial evaluation tool for users to manage their own sleep quality and, if necessary, consult a health professional. Further, the device may help users make simple changes to their habits to improve other health issues as well. Trial registration: NCT04568408 (Registered 23 September 2020).

Expression of miR-28-3p in patients with Alzheimer's disease before and after treatment and its clinical value

Expression of miR-28-3p in patients with Alzheimer's disease (AD) before and after treatment and clinical value of miR-28-3p were determined. There were three groups: 68 AD patients treated with donepezil combined with basic therapy in The People's Hospital of Shouguang collected as an AD group, 70 patients with mild cognitive impairment (MCI) as an MCI group, and 75 healthy people as a normal group. Serum miR-28-3p was detected by qRT-PCR. The Montreal cognitive assessment scale (MoCA), mini mental state examination scale (MMSE), activities of daily living scale (ADL) and homocysteine (Hcy) were adopted to assess patients before and after treatment. miR-28-3p in normal group was significantly lower than that in other two groups, and miR-28-3p in MCI group was significantly lower than that in AD group (P<0.001). miR-28-3p correlated with the course and severity of patients. miR-28-3p in AD group after treatment was significantly lower than that before treatment (P<0.001). ADL and Hcy of AD patients after treatment were significantly lower than before treatment (P<0.05), and MMSE and MoCA after treatment were significantly higher than before treatment (P<0.05). Before and after treatment, miR-28-3p was significantly positively correlated with ADL score and Hcy level, but negatively correlated with MMSE score and MoCA score. Analysis of the working characteristic curve of the patients indicated that miR-28-3p can be used for diagnosis of AD patients. Donepezil therapy may reduce miR-28-3p level to alleviate the symptoms of AD patients, and miR-28-3p level can be used as an early diagnosis and prognosis evaluation of AD patients.