Sleep-disordered breathing was associated with lower health-related quality of life and cognitive function in a cross-sectional study of older adults

Nocturnal hypoxia and age-related macular degeneration

BACKGROUND

Nocturnal hypoxia is common, under-diagnosed and is found in the same demographic at risk of age-related macular degeneration (AMD). The objective of this study was to determine any association between nocturnal hypoxia and AMD, its severity, and the high-risk sub-phenotype of reticular pseudodrusen (RPD).

METHODS

This cross-sectional study included participants aged ≥50 years with AMD, or normal controls, exclusive of those on treatment for obstructive sleep apnoea. All participants had at home, overnight (up to 3 nights) pulse oximetry recordings and multimodal imaging to classify AMD. Classification of Obstructive Sleep Apnea (OSA) was determined based on oxygen desaturation index [ODI] with mild having values of 5-15 and moderate-to-severe >15.

RESULTS

A total of 225 participants were included with 76% having AMD, of which 42% had coexistent RPD. Of the AMD participants, 53% had early/intermediate AMD, 30% had geographic atrophy (GA) and 17% had neovascular AMD (nAMD). Overall, mild or moderate-to-severe OSAwas not associated with an increased odds of having AMD nor AMD with RPD (p ≥ 0.180). However, moderate-to-severe OSA was associated with increased odds of having nAMD (odds ratio = 6.35; 95% confidence interval = 1.18 to 34.28; p = 0.032), but not early/intermediate AMD or GA, compared to controls (p ≥ 0.130). Mild OSA was not associated with differences in odds of having AMD of any severity (p ≥ 0.277).

CONCLUSIONS

There was an association between nocturnal hypoxia as measured by the ODI and nAMD. Hence, nocturnal hypoxia may be an under-appreciated important modifiable risk factor for nAMD.

Level 2 Polysomnography for the Diagnosis of Sleep Disorders: A Health Technology Assessment

Background

It is estimated that half of Canadians have insufficient sleep, which over time is associated with poor physical and mental health. Currently, the only publicly funded option for the diagnosis of sleep disorders in Ontario is an in-person overnight sleep study, performed in a hospital or independent health facility (known as a level 1 polysomnography). Level 2 polysomnography has been proposed as an alternative that can be conducted at home for the diagnosis of suspected sleep disorders, if considered to have sufficient diagnostic accuracy. We conducted a health technology assessment of level 2 polysomnography for the diagnosis of suspected sleep disorders in adults and children, which included an evaluation of the test performance, cost-effectiveness, and budget impact of publicly funding level 2 polysomnography, and the experiences, preferences, and values of people with suspected sleep disorders.

Methods

We performed a systematic literature search of the clinical evidence to identify diagnostic accuracy, test failures and subjective measures of patient preferences. We assessed the risk of bias of each included study (using the Quality Assessment of Diagnostic Accuracy Studies [QUADAS-2] tool) and the quality of the body of evidence (according to Grading of Recommendations Assessment, Development, and Evaluation [GRADE] Working Group criteria). We performed a systematic literature search of economic evidence and conducted a primary economic evaluation and budget impact analysis to determine the cost-effectiveness and additional costs of publicly funding level 2 polysomnography for adults and children with suspected sleep disorders in Ontario. To contextualize the potential value of using level 2 polysomnography, we spoke with people with sleep disorders.

Results

We included 10 studies that reported on diagnostic accuracy and found level 2 polysomnography had sensitivity ranging between 0.76-1.0 and specificity ranging between 0.40-1.0 (GRADE: Moderate to Very low) when compared with level 1 polysomnography. Studies reported test failure rates from 0% to 20%, with errors present in both level 1 and level 2 tests conducted (GRADE: Very low). As well, some of these studies reported patients were found to have mixed opinions about their experiences, with more people preferring their experience with level 2 testing at home and having better quality of sleep compared with when they underwent level 1 testing (GRADE not conducted).Our primary economic evaluation showed that for adults with suspected sleep disorders, the new diagnostic pathway with level 2 polysomnography was equally effective (outcome: confirmed diagnosis at the end of the pathway) as the current practice diagnostic pathway with level 1 polysomnography. With the assumption of a lower technical fee for level 2 polysomnography, the new diagnostic pathway with level 2 polysomnography was less costly than the current practice diagnostic pathway (a saving of $27 per person with a wide 95% credible interval [95% CrI, -$137 to $121]), indicating that the results are highly uncertain. For children, a new diagnostic pathway with level 2 polysomnography was associated with additional costs (mean, $9.70; 95% CrI, -$125 to $190), and similarly, this estimate was highly uncertain.We estimated that the budget impact of publicly funding level 2 polysomnography for adults is uncertain and could range from savings of $22 million to additional costs of $43 million. Publicly funding a diagnostic pathway with level 2 polysomnography for children could result in additional costs of about $0.005 million over the next 5 years.People with whom we spoke reported that their sleep disorder negatively impacted their day-to-day lives, mental health, social and family relationships, and work. Participants who had experience with in-clinic (level 1) polysomnography described negative experiences they had at the clinic. Most people said they would prefer at-home (level 2) polysomnography over in-clinic (level 1) polysomnography, citing comfort and convenience as the main reasons; however, some people who have physical limitations preferred level 1 (in-clinic) polysomnography because they needed assistance to set up the equipment.

Conclusions

Level 2 polysomnography may have good test performance for adults and children, with adequate diagnostic accuracy, compared with level 1 polysomnography. The economic analyses showed that level 2 polysomnography for adults with suspected sleep disorders could be potentially cost saving but there is high uncertainty in the cost-effectiveness results. Given very limited information, the cost-effectiveness of this technology is also highly uncertain for children and young adults with suspected sleep disorders. The budget impact of publicly funding level 2 polysomnography for adults could range from savings of $22 million to additional costs of $43 million. Publicly funding level 2 polysomnography in children would require additional costs of about $0.005 million over the next 5 years. A clearer understanding of uptake of the technology, test costs, and the implementation pathway for adopting the technology is needed to improve the certainty of the cost-effectiveness and budget impact estimates. People with sleep disorders highlighted how important getting a diagnosis had been in order to be able to seek proper treatment for their sleep disorder and improve their lives. For many people with suspected sleep disorders, undergoing a sleep study at home would be a more comfortable and convenient option than undergoing a sleep study in clinic.

Biomarkers of sleep-wake disturbance as predictors of cognitive decline and accelerated disease progression

INTRODUCTION

In older adults, where sleep disturbances and cognitive impairment are common, mounting evidence suggests a potential connection between sleep and cognitive function, highlighting the significance of utilizing sleep as a biomarker for early detection of cognitive impairment to improve clinical outcomes in a noninvasive, cost-effective manner.

AREAS COVERED

This review describes the relationship between sleep and cognitive function in older adults, encompassing both subjective and objective measures of sleep quality, duration, architecture, and sleep-disordered breathing. The authors consider the directionality of the associations observed in prospective and cross-sectional studies, exploring whether sleep disturbances precede cognitive decline or vice versa. Furthermore, they discuss the potential bidirectional relationships between sleep and Alzheimer's disease (AD) risks in older adults while also examining the neurodegenerative pathways of this relationship.

EXPERT OPINION

Routine sleep monitoring in primary care settings has the potential to bolster early detection and treatment of sleep disturbance, and by extension, reduce the risk of dementia. Improving sleep assessment tools, such as wearables, provide scalable alternatives to traditional methods like polysomnography, potentially enabling widespread monitoring of sleep characteristics. Standardized measurement and inclusive participant recruitment are needed to enhance generalizability, while longitudinal studies are essential to understand the interaction between sleep and AD pathology.

Worldwide prevalence of sleep problems in community-dwelling older adults: A systematic review and meta-analysis

The understanding of the prevalence of sleep problems in older adults can provide a broad and reliable perspective into the occurrence of such issues among older adults. This systematic review and meta-analysis aimed to estimate the worldwide prevalence of sleep problems in community-dwelling older adults. Studies that provide information on the prevalence of sleep problems in community-dwelling older adults (≥60 years) were screened between December 2022 and March 2023. A total of 20,379 studies were identified in database searches, from which 252 were included in this review. These studies covered the last 35 years (from 1988 to 2023) and pooled a sample of 995,544 participants from 36 countries. The most frequent sleep problem worldwide was obstructive sleep apnea (46.0%), followed by poor sleep quality (40.0%), other sleep problems (37.0%), insomnia (29.0%), and excessive daytime sleepiness (19.0%). No significant difference in the prevalence estimates of all sleep problems was observed between the sexes. This systematic review and meta-analysis showed a high prevalence of some sleep problems, mainly obstructive sleep apnea, poor sleep quality, and other sleep problems. Our estimates can be useful for managers and policymakers in planning healthcare strategies for sleep problems aimed at the older population.

Focus of dental sleep medicine on obstructive sleep apnea in older adults: A narrative review

PURPOSE

To review dental sleep medicine in older adults based on the literature.

STUDY SELECTION

This narrative review focuses on sleep physiology, common sleep disorders, and obstructive sleep apnea (OSA) in older adults and their management.

RESULTS

Sleep physiology differs between older and younger adults, with sleep disturbances occurring more frequently in older adults. The prevalence of insomnia increases in older adults due to age-related changes in sleep physiology. Insomnia, sleep-disordered breathing, periodic limb movement disorder, restless legs syndrome, and rapid eye movement (REM) sleep behavior disorder are common sleep disorders in older adults. OSA is more prevalent in older adults, and its effects on them are considered more substantial than those on younger adults. The treatment of older patients with mandibular advancement devices may be less effective and more complex owing to potential impairments in oral and dental health. Furthermore, the prevalence of edentulism in older adults is decreasing while life expectancy is increasing.

CONCLUSIONS

As older adults have comorbidities that affect sleep quality, dentists should consider the effects of sleep physiology and sleep disorders in these patients. OSA may decrease the quality of life and increase the risk of developing other diseases. Therefore, dentists proposing treatment with mandibular advancement devices need to inform patients of their potential lack of efficacy and the requirement for careful follow-up owing to known and unknown side effects.

Obstructive sleep apnea and cognitive functioning in the older general population: The moderating effect of age, sex, ApoE4, and obesity

Research on the relationship between obstructive sleep apnea and cognitive functioning has yielded conflicting results, particularly in the older population, and moderators of this association have rarely been studied. Here we investigated the cross-sectional association between obstructive sleep apnea and cognitive functioning as well as the moderating effect of age, sex, apolipoprotein E4, and obesity on this association among community-dwelling older people. We analysed data from 496 participants (71.4 ± 4.4 years; 45.6% men) of the HypnoLaus study who underwent polysomnography and a battery of neuropsychological tests. The sample was categorised as no-to-mild obstructive sleep apnea (apnea-hypopnea index 0-14.9/h; reference), moderate obstructive sleep apnea (apnea-hypopnea index 15.0-29.9/h), or severe obstructive sleep apnea (apnea-hypopnea index ≥30/h). Regression and moderation analyses were performed with adjustment for confounders. Apolipoprotein E4 and obesity moderated the association between severe obstructive sleep apnea and processing speed, whereas no moderating effects were found for age and sex. In apolipoprotein E4 carriers only, severe obstructive sleep apnea was associated with lower performance in Stroop condition 1 (B = 3.13, p = 0.024). In obese participants only, severe obstructive sleep apnea was associated with lower performance in Stroop condition 1 (B = 3.02, p = 0.025) and Stroop condition 2 (B = 3.30, p = 0.034). Severe obstructive sleep apnea was also associated with lower executive function in the whole sample according to Stroop condition 3 (B = 3.44, p = 0.020) and Stroop interference score (B = 0.24, p = 0.006). Our findings support associations of severe obstructive sleep apnea (but not moderate obstructive sleep apnea) with lower performance in processing speed and executive function in the older general population. Apolipoprotein E4 and obesity appear to be vulnerability factors that strengthen the association between severe obstructive sleep apnea and lower performance in processing speed.

Sleep Disorders and Aging in Women

Women of advancing age can suffer from an array of sleep disorders. We review the changes in sleep architecture, the impact of hormonal changes on sleep, and the various sleep disorders in women of advancing age. A focused history in this population should include the temporal relation to menopause and comorbid conditions. Treatment options should involve patient preference and review of current medications and comorbid conditions to optimize sleep in this population.

Age- and sex-specific associations between obstructive sleep apnea risk and cognitive decline in middle-aged and older adults: A 3-year longitudinal analysis of the Canadian longitudinal study on aging

BACKGROUND

Whether obstructive sleep apnea (OSA) increases the risk of cognitive decline and how sex and age influence this association is not clear. Here, we characterized the sex- and age-specific associations between OSA risk and 3-year cognitive change in middle-aged and older adults.

METHODS

We included 24,819 participants aged 45-85 (52% women) from the Canadian Longitudinal Study on Aging. OSA risk was measured at baseline using the STOP combined to body mass index (STOP-B). Neuropsychological tests assessed memory, executive functioning, and psychomotor speed at baseline and at 3-year follow-up. We conducted age- and sex-specific linear mixed models to estimate the predictive role of baseline STOP-B score on 3-year cognitive change.

RESULTS

Men at high-risk for OSA aged 45-59 years showed a steeper decline in psychomotor speed (+13.2 [95% CI: -1.6, 27.9]) compared to men at low-risk. Men at high-risk for OSA aged 60-69 showed a steeper decline in mental flexibility (-1.2 [-1.9, -0.5]) and processing speed (+0.6 [0.3, 0.9]) than those at low-risk. Women at high-risk for OSA aged 45-59 showed a steeper decline in processing speed (+0.1 [-0.2, 0.4]) than women at low-risk, while women at high-risk ≥70 years had a steeper decline in memory (-0.2 [-0.6, 0.1]) and processing speed (+1.0 [0.4, 1.5]).

CONCLUSIONS

Associations between OSA risk and cognitive decline over 3 years depend on age and sex. Being at high-risk for OSA is associated with a generalized cognitive decline in attention and processing speed, while a memory decline is specific to older women (≥70 years).

Contemporary Concise Review 2022: Sleep

COVID-19 AND SLEEP: The COVID-19 pandemic is associated with an increase in insomnia and impaired sleep quality Health care workers are particularly susceptible and improved with cognitive behavioural therapy for insomnia (CBT-I) Long COVID has significant effects on sleep OSA impacts on the severity of acute COVID-19 illness OBSTRUCTIVE SLEEP APNOEA: Large trials of clinically representative patients confirm the cardiovascular benefits of CPAP treatment in OSA CPAP may improve long-term cognitive outcomes in OSA, but further research is needed Racial disparities in OSA prevalence and mortality risk are becoming evident Periodic evaluation of OSA risk in pregnancy is important as timing may be key for intervention to prevent or treat cardiovascular risk factors INSOMNIA: Comorbid insomnia and obstructive sleep apnoea (COMISA) can frequently co-exist and the combined negative effects of both may be deleterious, particularly to cardiovascular health There is evidence for effectiveness with novel orexin receptor antagonists.