Continuous Positive Airway Pressure Treatment in Patients with Alzheimer's Disease: A Systematic Review

Adherence to continuous positive airway pressure for the treatment of obstructive sleep apnea in neurodegenerative diseases: A systematic review

Obstructive sleep apnea (OSA) is prevalent in patients with neurodegenerative diseases and is associated with worse outcomes. Positive airway pressure therapy has the potential to benefit these patients but can be challenging in this population. Our primary aim was to describe positive pressure therapy adherence. Secondarily, we aimed at identifying identify predictors of adherence to treatment in adults with neurodegenerative diseases and OSA, and report the effect of PAP adherence on outcomes such as cognitive function, quality of life and patient/caregiver satisfaction. We performed a systematic review of the literature and identified seventeen studies, eight reporting on adults with obstructive sleep apnea and mild cognitive impairment (MCI) and/or Alzheimer's disease (AD), 6 with Parkinson's disease (PD), and 3 with multiple system atrophy (MSA). Meta-analyses were not performed due to lack of systematic and standardized reporting of the primary outcome. Study duration ranged from 6 weeks to an average of 3.3 years. PAP adherence definition was widely variable between studies. Attrition rates ranged from 12% to 75%. In MCI/AD, adherence rates ranged from 28% to 61% (study duration range: 3 weeks to 3.3 years). Younger age, race (white) and better CPAP confidence scores at 1 week were associated with more CPAP use while APOE4 positive and unmarried individuals were more likely to abandon CPAP. In most studies, adherent patients had improvement in excessive daytime sleepiness, depressive symptoms, sleep quality, ability to manage daily activities and certain aspects of cognition (composite score or global cognition, psychomotor speed, executive function), as well as less cognitive decline over time. Caregiver satisfaction was also better in PAP adherent patients in one study. In PD, 15-25% of individuals refused treatment with PAP upfront, and attrition ranged from 8 to 75%. Adherent patients used their device for an average of 3h27 to 5h12 per night (study duration range: 6 weeks to 12 months). Longer disease duration, worse motor symptoms or sleep quality and lower % of REM sleep were identified as predictors of lower PAP adherence in a preliminary study, while race (non-white) and sex (women) were linked to lower adherence in a large retrospective study. In the study reporting the highest attrition rate (75%), individuals had lower educational levels. PAP adherence improved daytime sleepiness, anxiety symptoms, sleep architecture and quality and global non-motor symptoms. However, in one short-term (3 weeks) study, there was no improvement in neuropsychological testing composite score. Three studies on MSA patients suffering from sleep-disordered breathing showed that most patients are accepting of PAP (69-72%) with an average nightly use of 4h42 to 6h18. Floppy epiglottis was more frequently seen in patients discontinuing PAP in one study. In one study, four adults with MSA and long-term PAP use reported better sleep and improved vigilance. Survival time was no different between treated and untreated individuals. In conclusion, PAP therapy is challenging in patients with OSA and NDD, as evidenced by the considerable attrition and low adherence rates reported in this systematic review. There is emerging evidence proposing OSA a treatable target to prevent clinical and functional deterioration in patients with neurodegenerative diseases and addressing potential barriers to PAP adherence is paramount to maximize adherence. Our systematic review outlines several of these potential barriers, underscoring the need for future studies to standardize the definition of and explore long-term adherence to PAP therapy and assess interventions that can optimize adherence in this patient population.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Obstructive Sleep Apnea - Influence on the Cardiovascular System and Cognition

Kardiovaskuläre und kognitive Erkrankungen sind ebenso wie die obstruktive Schlafapnoe sehr häufige Krankheiten mit einer erheblichen Beeinträchtigung der Lebensqualität und einer deutlichen sozioökonomischen Bedeutung. Die Auswirkungen einer unbehandelten obstruktiven Schlafapnoe (OSA) auf das kardiovaskuläre und kognitive Erkrankungsrisiko und die Therapieeffekte einer OSA sind für die meisten kardiovaskulären und kognitiven Folgeerkrankungen wissenschaftlich nachgewiesen. Für die klinische Praxis besteht ein deutlicher Bedarf nach mehr Interdisziplinarität. Aus schlafmedizinischer Sicht müssen bei der Therapieindikation das individuelle kardiovaskuläre und kognitive Risiko berücksichtigt und kognitive Erkrankungen bei der Beurteilung der Therapieintoleranz und residuellen Symptomatik beachtet werden. Aus internistischer Sicht sollte bei Patienten mit schlecht einstellbarem Hypertonus, Vorhofflimmern, koronarer Herzkrankheit und Schlaganfall die Abklärung einer OSA in die Diagnostik integriert werden. Bei Patienten mit milder kognitiver Beeinträchtigung, Alzheimer-Krankheit und Depression können sich die typischen Symptome wie Fatigue, Tagesmüdigkeit und Reduktion der kognitiven Leistungen mit OSA-Symptomen überschneiden. Die Diagnostik einer OSA sollte in die Abklärung dieser Krankheitsbilder integriert werden, da eine Therapie der OSA die kognitiven Beeinträchtigungen reduzieren und die Lebensqualität verbessern kann.

Cognition effectiveness of continuous positive airway pressure treatment in obstructive sleep apnea syndrome patients with cognitive impairment: a meta-analysis

Obstructive sleep apnea (OSA) is a common respiratory disorder characterized by recurrent pharyngeal collapses during sleep leading to intermittent hypoxia and sleep disruption. Cognitive challenges and high risks of cognitive impairment, including Alzheimer's disease (AD), are closely associated with OSA. Currently, continuous positive airway pressure (CPAP) is widely used in the treatment of OSA. However, whether CPAP benefits cognitive functions in patients with OSA remains elusive. Here, we identified published studies through a systematic review of PubMed, Cochrane Library, Embase, Wanfang Data, CBM, and CNKI from January 1, 1970, to July 1, 2020. 288 patients from 7 articles (one was excluded in the meta-analysis for it was a follow-up study) were included in the present study. It revealed that cognitive functions of OSA patients with mild cognitive impairment (MCI) or AD were mildly but significantly improved after CPAP treatment (SMD 0.49, 95% CI 0.11-0.86), especially long-term CPAP treatment (SMD 0.56, 95% CI 0.10-1.02, p = 0.02), as measured by Mini-Mental State Examination (MMSE) (SMD 0.49, 95%CI 0.11-0.86). However, no significant cognition benefits were detected by the Montreal Cognitive Assessment (SMD 0.43, 95% CI 0.85-1.72). In terms of heterogeneity, cognitive improvements by CPAP were detectable on OSA patients either at a younger age or over longer periods of CPAP treatment. Therefore, our findings highlight the partial efficiency of CPAP treatment in cognition improvement of OSA patients with MCI or AD.

Sleep disorders and late-onset epilepsy of unknown origin: Understanding new trajectories to brain amyloidopathy

The intertwining between epilepsy, sleep disorders and beta amyloid pathology has been progressively highlighted, as early identification and stratification of patients at high risk of cognitive decline is the need of the hour. Modification of the sleep-wake activity, such as sleep impairment or excessive daytime sleepiness, can critically affect cerebral beta amyloid levels. Both mice models and human studies have demonstrated a substantial increase in the burden of beta amyloid pathology after sleep-deprivation, with potential negative effects partially restored by sleep recovery. The accumulation of beta amyloid has been shown to be an early event in the course of Alzheimer's disease dementia. Beta amyloid accumulation has been linked to epileptic seizures epileptic seizures, with beta amyloid being itself pro-epileptogenic in mice models already at oligomeric stage, well before plaque deposition. Further supporting a potential relationship between beta amyloid and epilepsy: i) seizures happen in 1 out of oofut 10 patients with Alzheimer's disease in the prodromal stage, ii) epileptic activity accelerates cognitive decline in Alzheimer's disease, iii) people with late-onset epilepsy present a critically high risk of developing dementia. In this Review we highlight the role of beta amyloid as a potential shared mechanisms between sleep disorders, late-onset epilepsy, and cognitive decline.