Efficacy of slow oscillatory‐transcranial direct current stimulation on EEG and memory – contribution of an inter‐individual factor

Towards Optimization of Oscillatory Stimulation During Sleep

BACKGROUND

Oscillatory rhythms during sleep, such as slow oscillations (SOs) and spindles and, most importantly, their coupling, are thought to underlie processes of memory consolidation. External slow oscillatory transcranial direct current stimulation (so-tDCS) with a frequency of 0.75 Hz has been shown to improve this coupling and memory consolidation; however, effects varied quite markedly between individuals, studies, and species. In this study, we aimed to determine how precisely the frequency of stimulation must match the naturally occurring SO frequency in individuals to best improve SO-spindle coupling. Moreover, we systematically tested stimulation durations necessary to induce changes.

MATERIALS AND METHODS

We addressed these questions by comparing so-tDCS with individualized frequency to standardized frequency of 0.75 Hz in a within-subject design with 28 older participants during napping while stimulation train durations were systematically varied between 30 seconds, 2 minutes, and 5 minutes.

RESULTS

Stimulation trains as short as 30 seconds were sufficient to modulate the coupling between SOs and spindle activity. Contrary to our expectations, so-tDCS with standardized frequency indicated stronger aftereffects regarding SO-spindle coupling than individualized frequency. Angle and variance of spindle maxima occurrence during the SO cycle were similarly modulated.

CONCLUSIONS

In sum, short stimulation trains were sufficient to induce significant changes in sleep physiology, allowing for more trains of stimulation, which provides methodological advantages and possibly even larger behavioral effects in future studies. Regarding individualized stimulation frequency, further options of optimization need to be investigated, such as closed-loop stimulation, to calibrate stimulation frequency to the SO frequency at the time of stimulation onset.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT04714879.

Memory ability and retention performance relate differentially to sleep depth and spindle type

Temporal interactions between non-rapid eye movement (NREM) sleep rhythms especially the coupling between cortical slow oscillations (SO, ∼1 Hz) and thalamic spindles (∼12 Hz) have been proposed to contribute to multi-regional interactions crucial for memory processing and cognitive ability. We investigated relationships between NREM sleep depth, sleep spindles and SO-spindle coupling regarding memory ability and memory consolidation in healthy humans. Findings underscore the functional relevance of spindle dynamics (slow versus fast), SO-phase, and most importantly NREM sleep depth for cognitive processing. Cross-frequency coupling analyses demonstrated stronger precise temporal coordination of slow spindles to SO down-state in N2 for subjects with higher general memory ability. A GLM model underscored this relationship, and furthermore that fast spindle properties were predictive of overnight memory consolidation. Our results suggest cognitive fingerprints dependent on conjoint fine-tuned SO-spindle temporal coupling, spindle properties, and brain sleep state.

Closed-loop acoustic stimulation during an afternoon nap to modulate subsequent encoding

Sleep is able to contribute not only to memory consolidation, but also to post-sleep learning. The notion exists that either synaptic downscaling or another process during sleep increase post-sleep learning capacity. A correlation between augmentation of the sleep slow oscillation and hippocampal activation at encoding support the contribution of sleep to encoding of declarative memories. In the present study, the effect of closed-loop acoustic stimulation during an afternoon nap on post-sleep encoding of two verbal (word pairs, verbal learning and memory test) and non-verbal (figural pairs) tasks and on electroencephalogram during sleep and learning were investigated in young healthy adults (N = 16). Closed-loop acoustic stimulation enhanced slow oscillatory and spindle activity, but did not affect encoding at the group level. Subgroup analyses and comparisons with similar studies lead us to the tentative conclusion that further parameters such as time of day and subjects' cognitive ability influenced responses to closed-loop acoustic stimulation.

Brain Stimulation for Improving Sleep and Memory

Over the past few decades, the importance of sleep has become increasingly recognized for many physiologic functions, including cognition. Many studies have reported the deleterious effect of sleep loss or sleep disruption on cognitive performance. Beyond ensuring adequate sleep quality and duration, discovering methods to enhance sleep to augment its restorative effects is important to improve learning in many populations, such as the military, students, age-related cognitive decline, and cognitive disorders.

Non-invasive brain stimulation and neuroenhancement

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The available data frame with a wide parameter space of tES does not allow an overarching protocol recommendation.

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Established engineering risk-management procedures with regard to manufacturing should be followed.

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Consensus among experts is that tES for neuroenhancement is safe as long as tested protocols are followed.

Attempts to enhance human memory and learning ability have a long tradition in science. This topic has recently gained substantial attention because of the increasing percentage of older individuals worldwide and the predicted rise of age-associated cognitive decline in brain functions. Transcranial brain stimulation methods, such as transcranial magnetic (TMS) and transcranial electric (tES) stimulation, have been extensively used in an effort to improve cognitive functions in humans.

Here we summarize the available data on low-intensity tES for this purpose, in comparison to repetitive TMS and some pharmacological agents, such as caffeine and nicotine. There is no single area in the brain stimulation field in which only positive outcomes have been reported. For self-directed tES devices, how to restrict variability with regard to efficacy is an essential aspect of device design and function. As with any technique, reproducible outcomes depend on the equipment and how well this is matched to the experience and skill of the operator. For self-administered non-invasive brain stimulation, this requires device designs that rigorously incorporate human operator factors. The wide parameter space of non-invasive brain stimulation, including dose (e.g., duration, intensity (current density), number of repetitions), inclusion/exclusion (e.g., subject’s age), and homeostatic effects, administration of tasks before and during stimulation, and, most importantly, placebo or nocebo effects, have to be taken into account. The outcomes of stimulation are expected to depend on these parameters and should be strictly controlled. The consensus among experts is that low-intensity tES is safe as long as tested and accepted protocols (including, for example, dose, inclusion/exclusion) are followed and devices are used which follow established engineering risk-management procedures. Devices and protocols that allow stimulation outside these parameters cannot claim to be “safe” where they are applying stimulation beyond that examined in published studies that also investigated potential side effects.

Brain stimulation devices marketed for consumer use are distinct from medical devices because they do not make medical claims and are therefore not necessarily subject to the same level of regulation as medical devices (i.e., by government agencies tasked with regulating medical devices). Manufacturers must follow ethical and best practices in marketing tES stimulators, including not misleading users by referencing effects from human trials using devices and protocols not similar to theirs.

Real-Time Excitation of Slow Oscillations during Deep Sleep Using Acoustic Stimulation

Slow-wave synchronous acoustic stimulation is a promising research and therapeutic tool. It is essential to clearly understand the principles of the synchronization methods, to know their performances and limitations, and, most importantly, to have a clear picture of the effect of stimulation on slow-wave activity (SWA). This paper covers the mentioned and currently missing parts of knowledge that are essential for the appropriate development of the method itself and future applications. Artificially streamed real sleep EEG data were used to quantitatively compare the two currently used real-time methods: the phase-locking loop (PLL) and the fixed-step stimulus in our own implementation. The fixed-step stimulation method was concluded to be more reliable and practically applicable compared to the PLL method. The sleep experiment with chronic insomnia patients in our sleep laboratory was analyzed in order to precisely characterize the effect of sound stimulation during deep sleep. We found that there is a significant phase synchronization of delta waves, which were shown to be the most sensitive metric of the effect of acoustic stimulation compared to commonly used averaged signal and power analyses. This finding may change the understanding of the effect and function of the SWA stimulation described in the literature.

Spontaneous slow oscillation - slow spindle features predict induced overnight memory retention

Study Objectives

Synchronization of neural activity within local networks and between brain regions is a major contributor to rhythmic field potentials such as the EEG. On the other hand, dynamic changes in microstructure and activity are reflected in the EEG, for instance slow oscillation (SO) slope can reflect synaptic strength. SO-spindle coupling is a measure for neural communication. It was previously associated with memory consolidation, but also shown to reveal strong interindividual differences. In studies, weak electric current stimulation has modulated brain rhythms and memory retention. Here, we investigate whether SO-spindle coupling and SO slope during baseline sleep are associated with (predictive of) stimulation efficacy on retention performance.

Methods

Twenty-five healthy subjects participated in three experimental sessions. Sleep-associated memory consolidation was measured in two sessions, in one anodal transcranial direct current stimulation oscillating at subjects individual SO frequency (so-tDCS) was applied during nocturnal sleep. The third session was without a learning task (baseline sleep). The dependence on SO-spindle coupling and SO-slope during baseline sleep of so-tDCS efficacy on retention performance were investigated.

Results

Stimulation efficacy on overnight retention of declarative memories was associated with nesting of slow spindles to SO trough in deep nonrapid eye movement baseline sleep. Steepness and direction of SO slope in baseline sleep were features indicative for stimulation efficacy.

Conclusions

Findings underscore a functional relevance of activity during the SO up-to-down state transition for memory consolidation and provide support for distinct consolidation mechanisms for types of declarative memories.

Shaping the slow waves of sleep: A systematic and integrative review of sleep slow wave modulation in humans using non-invasive brain stimulation

The experimental study of electroencephalographic slow wave sleep (SWS) stretches over more than half a century and has corroborated its importance for basic physiological processes, such as brain plasticity, metabolism and immune system functioning. Alterations of SWS in aging or pathological conditions suggest that modulating SWS might constitute a window for clinically relevant interventions. This work provides a systematic and integrative review of SWS modulation through non-invasive brain stimulation in humans. A literature search using PubMed, conducted in May 2020, identified 3220 studies, of which 82 fulfilled inclusion criteria. Three approaches have been adopted to modulate the macro- and microstructure of SWS, namely auditory, transcranial electrical and transcranial magnetic stimulation. Our current knowledge about the modulatory mechanisms, the space of stimulation parameters and the physiological and behavioral effects are reported and evaluated. The integration of findings suggests that sleep slow wave modulation bears the potential to promote our understanding of the functions of SWS and to develop new treatments for conditions of disrupted SWS.

The Treatment of Sleep Dysfunction in Neurodegenerative Disorders

Sleep dysfunction is highly prevalent across the spectrum of neurodegenerative conditions and is a key determinant of quality of life for both patients and their families. Mounting recent evidence also suggests that such dysfunction exacerbates cognitive and affective clinical features of neurodegeneration, as well as disease progression through acceleration of pathogenic processes. Effective assessment and treatment of sleep dysfunction in neurodegeneration is therefore of paramount importance; yet robust therapeutic guidelines are lacking, owing in part to a historical paucity of effective treatments and trials. Here, we review the common sleep abnormalities evident in neurodegenerative disease states and evaluate the latest evidence for traditional and emerging interventions, both pharmacological and nonpharmacological. Interventions considered include conservative measures, targeted treatments of specific clinical sleep pathologies, established sedating and alerting agents, melatonin, and orexin antagonists, as well as bright light therapy, behavioral measures, and slow-wave sleep augmentation techniques. We conclude by providing a suggested framework for treatment based on contemporary evidence and highlight areas that may emerge as major therapeutic advances in the near future.

The Effects of Transcranial Electrical Stimulation of the Brain on Sleep: A Systematic Review

Transcranial Electrical Stimulation (tES) is a promising non-invasive brain modulation tool. Over the past years, there have been several attempts to modulate sleep with tES-based approaches in both the healthy and pathological brains. However, data about the impact on measurable aspects of sleep remain scattered between studies, which prevent us from drawing firm conclusions. We conducted a systematic review of studies that explored the impact of tES on neurophysiological sleep oscillations, sleep patterns measured objectively with polysomnography, and subjective psychometric assessments of sleep in both healthy and clinical samples. We searched four main electronic databases to identify studies until February 2020. Forty studies were selected including 511 healthy participants and 452 patients. tES can modify endogenous brain oscillations during sleep. Results concerning changes in sleep patterns are conflicting, whereas subjective assessments show clear improvements after tES. Possible stimulation-induced mechanisms within specific cortico-subcortical sleep structures and networks are discussed. Although these findings cannot be directly transferred to the clinical practice and sleep-enhancing devices development for healthy populations, they might help to pave the way for future researches in these areas. PROSPERO registration number 178910.

Neuromodulation of sleep rhythms in schizophrenia: Towards the rational design of non-invasive brain stimulation

Brain function critically depends on oscillatory synchronization of neuronal populations both during wake and sleep. Originally, neural oscillations have been discounted as an epiphenomenon. More recently, specific deficits in the structure of brain oscillations have been linked to psychiatric diseases. For example, schizophrenia is hallmarked by abnormalities in different brain oscillations. Key sleep rhythms during NEM sleep such as sleep spindles, which are implicated in memory consolidation and are related to cognitive functions, are strongly diminished in these patients compared to healthy controls. To date, it remains unclear whether these reductions in sleep oscillations are causal for the functional impairments observed in schizophrenia. The application of non-invasive brain stimulation permits the causal examination of brain network dynamics and will help to establish the causal association of sleep oscillations and symptoms of schizophrenia. To accomplish this, stimulation paradigms that selectively engage specific network targets such as sleep spindles or slow waves are needed. We propose that the successful development and application of these non-invasive brain stimulation approaches will require rational design that takes network dynamics and neuroanatomical information into account. The purpose of this article is to prepare the grounds for the next steps towards such rational design of non-invasive stimulation, with a special focus on electrical and auditory stimulation. First, we briefly summarize the deficits in network dynamics during sleep in schizophrenia. Then, we discuss today's and tomorrow's non-invasive brain stimulation modalities to engage these network targets.

Brain Stimulation for Improving Sleep and Memory

Given the critical role of sleep, particularly sleep slow oscillations, sleep spindles, and hippocampal sharp wave ripples, in memory consolidation, sleep enhancement represents a key opportunity to improve cognitive performance. Techniques such as transcranial electrical and magnetic stimulation and acoustic stimulation can enhance slow oscillations and sleep spindles and potentially improve memory. Targeted memory reactivation in sleep may enhance or stabilize memory consolidation. Each technique has technical considerations that may limit its broader clinical application. Therefore, neurostimulation to enhance sleep quality, in particular sleep slow oscillations, has the potential for improving sleep-related memory consolidation in healthy and clinical populations.

Brain Rhythms During Sleep and Memory Consolidation: Neurobiological Insights

Sleep can benefit memory consolidation. The characterization of brain regions underlying memory consolidation during sleep, as well as their temporal interplay, reflected by specific patterns of brain electric activity, is surfacing. Here, we provide an overview of recent concepts and results on the mechanisms of sleep-related memory consolidation. The latest studies strongly impacting future directions of research in this field are highlighted.

Distinct Montages of Slow Oscillatory Transcranial Direct Current Stimulation (so-tDCS) Constitute Different Mechanisms during Quiet Wakefulness

Slow oscillatory- (so-) tDCS has been applied in many sleep studies aimed to modulate brain rhythms of slow wave sleep and memory consolidation. Yet, so-tDCS may also modify coupled oscillatory networks. Efficacy of weak electric brain stimulation is however variable and dependent upon the brain state at the time of stimulation (subject and/or task-related) as well as on stimulation parameters (e.g., electrode placement and applied current. Anodal so-tDCS was applied during wakefulness with eyes-closed to examine efficacy when deviating from the dominant brain rhythm. Additionally, montages of different electrodes size and applied current strength were used. During a period of quiet wakefulness bilateral frontolateral stimulation (F3, F4; return electrodes at ipsilateral mastoids) was applied to two groups: ‘Group small’ (n = 16, f:8; small electrodes: 0.50 cm²; maximal current per electrode pair: 0.26 mA) and ‘Group Large’ (n = 16, f:8; 35 cm²; 0.35 mA). Anodal so-tDCS (0.75 Hz) was applied in five blocks of 5 min epochs with 1 min stimulation-free epochs between the blocks. A finger sequence tapping task (FSTT) was used to induce comparable cortical activity across sessions and subject groups. So-tDCS resulted in a suppression of alpha power over the parietal cortex. Interestingly, in Group Small alpha suppression occurred over the standard band (8–12 Hz), whereas for Group Large power of individual alpha frequency was suppressed. Group Small also revealed a decrease in FSTT performance at retest after stimulation. It is essential to include concordant measures of behavioral and brain activity to help understand variability and poor reproducibility in oscillatory-tDCS studies.

Opposite effect of motivated forgetting on sleep spindles during stage 2 and slow wave sleep

Memories selectively benefit from sleep. In addition to the importance of the consolidation of relevant memories, the capacity to forget unwanted memories is also crucial. We investigated the effect of suppressing unwanted memories on electroencephalography activity of subsequent sleep using a motivated forgetting (MF) paradigm as compared with a control non-forgetting task. Subjects were randomly assigned to nap or no-nap groups. We used a modified version of the think/no-think paradigm with dominant number of no-think words cued to be forgotten and included only subjects capable of suppressing unwanted memories by performing an initial subject inclusion experiment. In both groups and conditions, the performance of the subjects in recalling the word pairs learned in the beginning of the day was evaluated in a final recall test. We found that both nap and no-nap groups recalled significantly less no-think words in the MF condition compared to the control condition. Moreover, for the nap group, in the MF compared to the control condition, spindle power and density increased during stage 2 (S2) whereas they decreased during slow wave sleep (SWS). Interestingly, recall performance of no-think words was negatively correlated with spindle power during S2 whereas it was positively correlated with spindle power during SWS. These results indicate that sleep spindles are sensitive to the previous MF experiences and suggest a differential role of sleep spindles during S2 and SWS in memory processing during sleep.

Stimulating the sleeping brain: Current approaches to modulating memory-related sleep physiology

BACKGROUND

One of the most audacious proposals throughout the history of psychology was the potential ability to learn while we sleep. The idea penetrated culture via sci-fi movies and inspired the invention of devices that claimed to teach foreign languages, facts, and even quit smoking by simply listening to audiocassettes or other devices during sleep. However, the promises from this endeavor didn't stand up to experimental scrutiny, and the dream was shunned from the scientific community. Despite the historic evidence that the sleeping brain cannot learn new complex information (i.e., words, images, facts), a new wave of current interventions are demonstrating that sleep can be manipulated to strengthen recent memories.

NEW METHOD

Several recent approaches have been developed that play with the sleeping brain in order to modify ongoing memory processing. Here, we provide an overview of the available techniques to non-invasively modulate memory-related sleep physiology, including sensory, vestibular and electrical stimulation, as well as pharmacological approaches.

RESULTS

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COMPARISON WITH EXISTING METHODS

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CONCLUSIONS

Although the results are encouraging, suggesting that in general the sleeping brain may be optimized for better memory performance, the road to bring these techniques in free-living conditions is paved with unanswered questions and technical challenges that need to be carefully addressed.