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D'Rozario AL, Kao CH, Phillips CL, Mullins AE, Memarian N, Yee BJ, Duffy SL, Cho G, Wong KKH, Kremerskothen K, Chapman J, Haroutonian C, Bartlett DJ, Naismith SL, Grunstein RR. Region-specific changes in brain activity and memory after continuous positive airway pressure therapy in obstructive sleep apnea: a pilot high-density electroencephalography study. Sleep 2023; 46:zsad255. [PMID: 37777337 DOI: 10.1093/sleep/zsad255] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 08/24/2023] [Indexed: 10/02/2023] Open
Abstract
STUDY OBJECTIVES Limited channel electroencephalography (EEG) investigations in obstructive sleep apnea (OSA) have revealed deficits in slow wave activity (SWA) and spindles during sleep and increased EEG slowing during resting wakefulness. High-density EEG (Hd-EEG) has also detected local parietal deficits in SWA (delta power) during NREM. It is unclear whether effective continuous positive airway pressure (CPAP) treatment reverses regional SWA deficits, and other regional sleep and wake EEG abnormalities, and whether any recovery relates to improved overnight memory consolidation. METHODS A clinical sample of men with moderate-severe OSA underwent sleep and resting wake recordings with 256-channel Hd-EEG before and after 3 months of CPAP. Declarative and procedural memory tasks were administered pre- and post-sleep. Topographical spectral power maps and differences between baseline and treatment were compared using t-tests and statistical nonparametric mapping (SnPM). RESULTS In 11 compliant CPAP users (5.2 ± 1.1 hours/night), total sleep time did not differ after CPAP but N1 and N2 sleep were lower and N3 was higher. Centro-parietal gamma power during N3 increased and fronto-central slow spindle activity during N2 decreased (SnPM < 0.05). No other significant differences in EEG power were observed. When averaged specifically within the parietal region, N3 delta power increased after CPAP (p = 0.0029) and was correlated with the change in overnight procedural memory consolidation (rho = 0.79, p = 0.03). During resting wakefulness, there were trends for reduced delta and theta power. CONCLUSIONS Effective CPAP treatment of OSA may correct regional EEG abnormalities, and regional recovery of SWA may relate to procedural memory improvements in the short term.
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Affiliation(s)
- Angela L D'Rozario
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- School of Psychological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Chien-Hui Kao
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
| | - Craig L Phillips
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Anna E Mullins
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine, New York City, NY, USA
| | - Negar Memarian
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
| | - Brendon J Yee
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health University of Sydney, Sydney, NSW, Australia
| | - Shantel L Duffy
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
| | - Garry Cho
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- School of Psychological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Keith K H Wong
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health University of Sydney, Sydney, NSW, Australia
| | - Kyle Kremerskothen
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
| | - Julia Chapman
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
| | - Carla Haroutonian
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Delwyn J Bartlett
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health University of Sydney, Sydney, NSW, Australia
| | - Sharon L Naismith
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Ron R Grunstein
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health University of Sydney, Sydney, NSW, Australia
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2
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Varga AW, Mullins AE, Kam K. Obstructive Sleep Apnea in Emotional Memory: Importance of Rapid Eye Movement Sleep and Window into Mental Health. Ann Am Thorac Soc 2023; 20:204-205. [PMID: 36723477 PMCID: PMC9989857 DOI: 10.1513/annalsats.202211-933ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Andrew W Varga
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anna E Mullins
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Korey Kam
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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4
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Kam K, Jun J, Parekh A, Bubu OM, Mullins AE, Gu C, Pham L, Wisniewski TM, Rapoport DM, Ayappa I, Osorio RS, Varga AW. Acute OSA Impacts Diurnal Alzheimer's Biomarkers through Nocturnal Hypoxemia and State Transitions. Am J Respir Crit Care Med 2022; 206:1039-1042. [PMID: 35696622 DOI: 10.1164/rccm.202202-0262le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Korey Kam
- Icahn School of Medicine at Mount Sinai New York, New York
| | | | - Ankit Parekh
- Icahn School of Medicine at Mount Sinai New York, New York
| | | | - Anna E Mullins
- Icahn School of Medicine at Mount Sinai New York, New York
| | - Chenjuan Gu
- Johns Hopkins University Baltimore, Maryland
| | - Luu Pham
- Johns Hopkins University Baltimore, Maryland
| | | | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai New York, New York
| | | | - Andrew W Varga
- Icahn School of Medicine at Mount Sinai New York, New York
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5
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Bubu OM, Kaur SS, Mbah AK, Umasabor-Bubu OQ, Cejudo JR, Debure L, Mullins AE, Parekh A, Kam K, Osakwe ZT, Williams ET, Turner AD, Glodzik L, Rapoport DM, Ogedegbe G, Fieremans E, de Leon MJ, Ayappa I, Jean-Louis G, Masurkar AV, Varga AW, Osorio RS. Obstructive Sleep Apnea and Hypertension with Longitudinal Amyloid-β Burden and Cognitive Changes. Am J Respir Crit Care Med 2022; 206:632-636. [PMID: 35550019 PMCID: PMC9716897 DOI: 10.1164/rccm.202201-0107le] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Ankit Parekh
- Icahn School of Medicine at Mount SinaiNew York, New York
| | - Korey Kam
- Icahn School of Medicine at Mount SinaiNew York, New York
| | | | | | | | | | | | | | | | | | - Indu Ayappa
- Icahn School of Medicine at Mount SinaiNew York, New York
| | | | | | | | - Ricardo S. Osorio
- New York UniversityNew York, New York
- Nathan S. Kline Institute for Psychiatric ResearchOrangeburg, New York
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6
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Bubu OM, Williams ET, Umasabor-Bubu OQ, Kaur SS, Turner AD, Blanc J, Cejudo JR, Mullins AE, Parekh A, Kam K, Osakwe ZT, Nguyen AW, Trammell AR, Mbah AK, de Leon M, Rapoport DM, Ayappa I, Ogedegbe G, Jean-Louis G, Masurkar AV, Varga AW, Osorio RS. Interactive Associations of Neuropsychiatry Inventory-Questionnaire Assessed Sleep Disturbance and Vascular Risk on Alzheimer's Disease Stage Progression in Clinically Normal Older Adults. Front Aging Neurosci 2021; 13:763264. [PMID: 34955813 PMCID: PMC8704133 DOI: 10.3389/fnagi.2021.763264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To determine whether sleep disturbance (SD) and vascular-risk interact to promote Alzheimer's disease (AD) stage-progression in normal, community-dwelling older adults and evaluate their combined risk beyond that of established AD biomarkers. Methods: Longitudinal data from the National Alzheimer's Coordinating Center Uniform-Dataset. SD data (i.e., SD+ vs. SD-), as characterized by the Neuropsychiatric Inventory-Questionnaire, were derived from 10,600 participants at baseline, with at-least one follow-up visit. A subset (n = 361) had baseline cerebrospinal fluid (CSF) biomarkers and MRI data. The Framingham heart study general cardiovascular disease (FHS-CVD) risk-score was used to quantify vascular risk. Amnestic mild cognitive impairment (aMCI) diagnosis during follow-up characterized AD stage-progression. Logistic mixed-effects models with random intercept and slope examined the interaction of SD and vascular risk on prospective aMCI diagnosis. Results: Of the 10,600 participants, 1,017 (9.6%) reported SD and 6,572 (62%) were female. The overall mean (SD) age was 70.5 (6.5), and follow-up time was 5.1 (2.7) years. SD and the FHS-CVD risk-score were each associated with incident aMCI (aOR: 1.42 and aOR: 2.11, p < 0.01 for both). The interaction of SD and FHS-CVD risk-score with time was significant (aOR: 2.87, p < 0.01), suggesting a synergistic effect. SD and FHS-CVD risk-score estimates remained significantly associated with incident aMCI even after adjusting for CSF (Aβ, T-tau, P-tau) and hippocampal volume (n = 361) (aOR: 2.55, p < 0.01), and approximated risk-estimates of each biomarker in the sample where data was available. Conclusions: Clinical measures of sleep and vascular risk may complement current AD biomarkers in assessing risk of cognitive decline in older adults.
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Affiliation(s)
- Omonigho M Bubu
- Department of Psychiatry, Center for Sleep and Brain Health, NYU Grossman School of Medicine, New York, NY, United States.,Department of Population Health, Center for Healthful Behavior Change, NYU Grossman School of Medicine, New York, NY, United States
| | - Ellita T Williams
- Department of Population Health, Center for Healthful Behavior Change, NYU Grossman School of Medicine, New York, NY, United States
| | - Ogie Q Umasabor-Bubu
- Division of Epidemiology and Infection Control, State University New York (SUNY) Downstate Medical Center, Brooklyn, NY, United States
| | - Sonya S Kaur
- Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Arlener D Turner
- Department of Psychiatry and Behavioral Sciences, Center for Translational Sleep and Circadian Sciences (TSCS), University of Miami Miller School of Medicine, Miami, FL, United States
| | - Judite Blanc
- Department of Psychiatry and Behavioral Sciences, Center for Translational Sleep and Circadian Sciences (TSCS), University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jaime Ramos Cejudo
- Department of Psychiatry, Center for Sleep and Brain Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Anna E Mullins
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ankit Parekh
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Korey Kam
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zainab T Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, United States
| | - Ann W Nguyen
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Antoine R Trammell
- Division of General Medicine and Geriatrics, Department of Medicine, Emory Brain Health Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Alfred K Mbah
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, United States
| | - Mony de Leon
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - David M Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Indu Ayappa
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Gbenga Ogedegbe
- Department of Population Health, Center for Healthful Behavior Change, NYU Grossman School of Medicine, New York, NY, United States
| | - Girardin Jean-Louis
- Department of Psychiatry, Center for Sleep and Brain Health, NYU Grossman School of Medicine, New York, NY, United States.,Department of Psychiatry and Behavioral Sciences, Center for Translational Sleep and Circadian Sciences (TSCS), University of Miami Miller School of Medicine, Miami, FL, United States
| | - Arjun V Masurkar
- Department of Neurology, Center for Cognitive Neurology, New York University School of Medicine, New York, NY, United States
| | - Andrew W Varga
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ricardo S Osorio
- Department of Psychiatry, Center for Sleep and Brain Health, NYU Grossman School of Medicine, New York, NY, United States.,Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY, United States
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7
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Mullins AE, Parekh A, Kam K, Castillo B, Roberts ZJ, Fakhoury A, Valencia DI, Schoenholz R, Tolbert TM, Bronstein JZ, Mooney AM, Burschtin OE, Rapoport DM, Ayappa I, Varga AW. Selective Continuous Positive Airway Pressure Withdrawal With Supplemental Oxygen During Slow-Wave Sleep as a Method of Dissociating Sleep Fragmentation and Intermittent Hypoxemia-Related Sleep Disruption in Obstructive Sleep Apnea. Front Physiol 2021; 12:750516. [PMID: 34880775 PMCID: PMC8646104 DOI: 10.3389/fphys.2021.750516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) is considered to impair memory processing and increase the expression of amyloid-β (Aβ) and risk for Alzheimer’s disease (AD). Given the evidence that slow-wave sleep (SWS) is important in both memory and Aβ metabolism, a better understanding of the mechanisms by which OSA impacts memory and risk for AD can stem from evaluating the role of disruption of SWS specifically and, when such disruption occurs through OSA, from evaluating the individual contributions of sleep fragmentation (SF) and intermittent hypoxemia (IH). In this study, we used continuous positive airway pressure (CPAP) withdrawal to recapitulate SWS-specific OSA during polysomnography (PSG), creating conditions of both SF and IH in SWS only. During separate PSGs, we created the conditions of SWS fragmentation but used oxygen to attenuate IH. We studied 24 patients (average age of 55 years, 29% female) with moderate-to-severe OSA [Apnea-Hypopnea Index (AHI); AHI4% > 20/h], who were treated and adherent to CPAP. Participants spent three separate nights in the laboratory under three conditions as follows: (1) consolidated sleep with CPAP held at therapeutic pressure (CPAP); (2) CPAP withdrawn exclusively in SWS (OSASWS) breathing room air; and (3) CPAP withdrawn exclusively in SWS with the addition of oxygen during pressure withdrawal (OSASWS + O2). Multiple measures of SF (e.g., arousal index) and IH (e.g., hypoxic burden), during SWS, were compared according to condition. Arousal index in SWS during CPAP withdrawal was significantly greater compared to CPAP but not significantly different with and without oxygen (CPAP = 1.1/h, OSASWS + O2 = 10.7/h, OSASWS = 10.6/h). However, hypoxic burden during SWS was significantly reduced with oxygen compared to without oxygen [OSASWS + O2 = 23 (%min)/h, OSASWS = 37 (%min)/h]. No significant OSA was observed in non-rapid eye movement (REM) stage 1 (NREM 1), non-REM stage 2 (NREM 2), or REM sleep (e.g., non-SWS) in any condition. The SWS-specific CPAP withdrawal induces OSA with SF and IH. The addition of oxygen during CPAP withdrawal results in SF with significantly less severe hypoxemia during the induced respiratory events in SWS. This model of SWS-specific CPAP withdrawal disrupts SWS with a physiologically relevant stimulus and facilitates the differentiation of SF and IH in OSA.
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Affiliation(s)
- Anna E Mullins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ankit Parekh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Korey Kam
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Bresne Castillo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zachary J Roberts
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ahmad Fakhoury
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daphne I Valencia
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Reagan Schoenholz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Thomas M Tolbert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jason Z Bronstein
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Anne M Mooney
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Omar E Burschtin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - David M Rapoport
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Indu Ayappa
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Andrew W Varga
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Parekh A, Kam K, Mullins AE, Castillo B, Berkalieva A, Mazumdar M, Varga AW, Eckert DJ, Rapoport DM, Ayappa I. Altered K-complex morphology during sustained inspiratory airflow limitation is associated with next-day lapses in vigilance in obstructive sleep apnea. Sleep 2021; 44:zsab010. [PMID: 33433607 PMCID: PMC8271137 DOI: 10.1093/sleep/zsab010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/14/2020] [Indexed: 01/25/2023] Open
Abstract
STUDY OBJECTIVES Determine if changes in K-complexes associated with sustained inspiratory airflow limitation (SIFL) during N2 sleep are associated with next-day vigilance and objective sleepiness. METHODS Data from thirty subjects with moderate-to-severe obstructive sleep apnea who completed three in-lab polysomnograms: diagnostic, on therapeutic continuous positive airway pressure (CPAP), and on suboptimal CPAP (4 cmH2O below optimal titrated CPAP level) were analyzed. Four 20-min psychomotor vigilance tests (PVT) were performed after each PSG, every 2 h. Changes in the proportion of spontaneous K-complexes and spectral characteristics surrounding K-complexes were evaluated for K-complexes associated with both delta (∆SWAK), alpha (∆αK) frequencies. RESULTS Suboptimal CPAP induced SIFL (14.7 (20.9) vs 2.9 (9.2); %total sleep time, p < 0.001) with a small increase in apnea-hypopnea index (AHI3A: 6.5 (7.7) vs 1.9 (2.3); p < 0.01) versus optimal CPAP. K-complex density (num./min of stage N2) was higher on suboptimal CPAP (0.97 ± 0.7 vs 0.65±0.5, #/min, mean ± SD, p < 0.01) above and beyond the effect of age, sex, AHI3A, and duration of SIFL. A decrease in ∆SWAK with suboptimal CPAP was associated with increased PVT lapses and explained 17% of additional variance in PVT lapses. Within-night during suboptimal CPAP K-complexes appeared to alternate between promoting sleep and as arousal surrogates. Electroencephalographic changes were not associated with objective sleepiness. CONCLUSIONS Sustained inspiratory airflow limitation is associated with altered K-complex morphology including the increased occurrence of K-complexes with bursts of alpha as arousal surrogates. These findings suggest that sustained inspiratory flow limitation may be associated with nonvisible sleep fragmentation and contribute to increased lapses in vigilance.
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Affiliation(s)
- Ankit Parekh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Korey Kam
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anna E Mullins
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bresne Castillo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Asem Berkalieva
- Institute for Healthcare Delivery and Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Madhu Mazumdar
- Institute for Healthcare Delivery and Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew W Varga
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danny J Eckert
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, SA, Australia
| | - David M Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Indu Ayappa
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Mullins AE, Williams MK, Kam K, Parekh A, Bubu OM, Castillo B, Roberts ZJ, Rapoport DM, Ayappa I, Osorio RS, Varga AW. Effects of obstructive sleep apnea on human spatial navigational memory processing in cognitively normal older individuals. J Clin Sleep Med 2021; 17:939-948. [PMID: 33399067 PMCID: PMC8320476 DOI: 10.5664/jcsm.9080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) prevalence increases with age, but whether OSA-related sleep disruption could interrupt the processing of previously encoded wake information thought to normally occur during sleep in cognitively normal older adults remains unknown. METHODS Fifty-two older (age = 66.9 ± 7.7 years, 56% female), community-dwelling, cognitively normal adults explored a 3-D maze environment and then performed 3 timed trials before (evening) and after (morning) sleep recorded with polysomnography with a 20-minute morning psychomotor vigilance test. RESULTS Twenty-two (22) participants had untreated OSA [apnea-hypopnea index (AHI4%) ≥ 5 events/h] where severity was mild on average [median (interquartile range); AHI4% = 11.0 (20.7) events/h] and 30 participants had an AHI4% < 5 events/h. No significant differences were observed in overnight percent change in completion time or in the pattern of evening presleep maze performance. However, during the morning postsleep trials, there was a significant interaction between OSA group and morning trial number such that participants with OSA performed worse on average with each subsequent morning trial, whereas those without OSA showed improvements. There were no significant differences in morning psychomotor vigilance test performance, suggesting that vigilance is unlikely to account for this difference in morning maze performance. Increasing relative frontal slow wave activity was associated with better overnight maze performance improvement in participants with OSA (r = .51, P = .02) but not in those without OSA, and no differences in slow wave activity were observed between groups. CONCLUSIONS OSA alters morning performance in spatial navigation independent of a deleterious effect on morning vigilance or evening navigation performance. Relative frontal slow wave activity is associated with overnight performance change in older participants with OSA, but not those without.
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Affiliation(s)
- Anna E. Mullins
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Masrai K. Williams
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Korey Kam
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ankit Parekh
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Omonigho M. Bubu
- Center for Sleep and Brain Health, Department of Psychiatry, NYU Grossman School of Medicine, New York, New York
| | - Bresne Castillo
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zachary J. Roberts
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David M. Rapoport
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Indu Ayappa
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ricardo S. Osorio
- Center for Sleep and Brain Health, Department of Psychiatry, NYU Grossman School of Medicine, New York, New York
| | - Andrew W. Varga
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Mullins AE, Kam K, Parekh A, Bubu OM, Osorio RS, Varga AW. Obstructive Sleep Apnea and Its Treatment in Aging: Effects on Alzheimer's disease Biomarkers, Cognition, Brain Structure and Neurophysiology. Neurobiol Dis 2020; 145:105054. [PMID: 32860945 PMCID: PMC7572873 DOI: 10.1016/j.nbd.2020.105054] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 08/13/2020] [Accepted: 08/18/2020] [Indexed: 02/08/2023] Open
Abstract
Here we review the impact of obstructive sleep apnea (OSA) on biomarkers of Alzheimer's disease (AD) pathogenesis, neuroanatomy, cognition and neurophysiology, and present the research investigating the effects of continuous positive airway pressure (CPAP) therapy. OSA is associated with an increase in AD markers amyloid-β and tau measured in cerebrospinal fluid (CSF), by Positron Emission Tomography (PET) and in blood serum. There is some evidence suggesting CPAP therapy normalizes AD biomarkers in CSF but since mechanisms for amyloid-β and tau production/clearance in humans are not completely understood, these findings remain preliminary. Deficits in the cognitive domains of attention, vigilance, memory and executive functioning are observed in OSA patients with the magnitude of impairment appearing stronger in younger people from clinical settings than in older community samples. Cognition improves with varying degrees after CPAP use, with the greatest effect seen for attention in middle age adults with more severe OSA and sleepiness. Paradigms in which encoding and retrieval of information are separated by periods of sleep with or without OSA have been done only rarely, but perhaps offer a better chance to understand cognitive effects of OSA than isolated daytime testing. In cognitively normal individuals, changes in EEG microstructure during sleep, particularly slow oscillations and spindles, are associated with biomarkers of AD, and measures of cognition and memory. Similar changes in EEG activity are reported in AD and OSA, such as "EEG slowing" during wake and REM sleep, and a degradation of NREM EEG microstructure. There is evidence that CPAP therapy partially reverses these changes but large longitudinal studies demonstrating this are lacking. A diagnostic definition of OSA relying solely on the Apnea Hypopnea Index (AHI) does not assist in understanding the high degree of inter-individual variation in daytime impairments related to OSA or response to CPAP therapy. We conclude by discussing conceptual challenges to a clinical trial of OSA treatment for AD prevention, including inclusion criteria for age, OSA severity, and associated symptoms, the need for a potentially long trial, defining relevant primary outcomes, and which treatments to target to optimize treatment adherence.
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Affiliation(s)
- Anna E Mullins
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Korey Kam
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ankit Parekh
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Omonigho M Bubu
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY 10016, USA
| | - Ricardo S Osorio
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY 10016, USA
| | - Andrew W Varga
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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11
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Mullins AE, Kim JW, Wong KKH, Bartlett DJ, Vakulin A, Dijk DJ, Marshall NS, Grunstein RR, D'Rozario AL. Sleep EEG microstructure is associated with neurobehavioural impairment after extended wakefulness in obstructive sleep apnea. Sleep Breath 2020; 25:347-354. [PMID: 32772308 DOI: 10.1007/s11325-020-02066-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/07/2020] [Accepted: 03/17/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Using quantitative EEG (qEEG) analysis, we investigated sleep EEG microstructure as correlates of neurobehavioural performance after 24 h of extended wakefulness in untreated OSA. METHODS Eight male OSA patients underwent overnight polysomnography (PSG) at baseline followed by 40 h awake with repeated performance testing (psychomotor vigilance task [PVT] and AusEd driving simulator). EEG slowing during REM and spindle density during NREM sleep were calculated using power spectral analysis and a spindle detection algorithm at frontal and central electrode sites. Correlations between sleep EEG microstructure measures and performance after 24-h awake were assessed. RESULTS Greater EEG slowing during REM sleep was associated with slower PVT reaction times (rho = - 0.79, p = 0.02), more PVT lapses (rho = 0.87, p = 0.005) and more AusEd crashes (rho = 0.73, p = 0.04). Decreased spindle density in NREM sleep was also associated with slower PVT reaction times (rho = 0.89, p = 0.007). Traditional PSG measures of disease severity were not consistent correlates of neurobehavioural performance in OSA. CONCLUSIONS Sleep EEG microstructure measures recorded during routine PSG are associated with impaired vigilance in OSA patients after sleep deprivation. SIGNIFICANCE Quantitative brain oscillatory (or EEG)-based measures of sleep may better reflect the deleterious effects of untreated OSA than traditional PSG metrics in at-risk individuals. Trial Registration ACTRN12606000066583.
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Affiliation(s)
- Anna E Mullins
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia.
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.
- CRC for Alertness, Safety and Productivity, Melbourne, Australia.
- The Varga Laboratory, Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, 10029, USA.
| | - Jong W Kim
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Department of Healthcare IT, Inje University, Inje-ro 197, Kimhae, Kyunsangnam-do, 50834, South Korea
| | - Keith K H Wong
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, Sydney, NSW, Australia
| | - Delwyn J Bartlett
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew Vakulin
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Derk-Jan Dijk
- Surrey Sleep Research Centre, UK Dementia Research Institute at the University of Surrey, Guildford, UK
| | - Nathaniel S Marshall
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Ronald R Grunstein
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, Sydney, NSW, Australia
| | - Angela L D'Rozario
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, PO Box M77, Missenden Road, Sydney, NSW, 2050, Australia
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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12
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Mullins AE, Bagchi N, Parekh A, Kam K, Wang J, Williams MK, Rapoport DM, Ayappa I, Burschtin OE, Varga AW. 0838 Sex Specific Changes in Sleep Macro-Structure With Obstructive Sleep Apnea in a Large Clinical Population of Older Adults. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Sleep architecture is influenced by age and sex and is disrupted by obstructive sleep apnea (OSA) and periodic limb movements (PLM) of sleep. Although increasing OSA severity is thought to decrease both REM and slow wave sleep (SWS), it may do so in non-linear ways. Here, we aim to 1) compare sleep macrostructure between older men and women, 2) compare metrics of total and REM-specific OSA severity between older men and women, and 3) examine associations between metrics of OSA severity and REM sleep and SWS in a clinical sample.
Methods
Clinical in-lab diagnostic polysomnography (PSG) in adults ≥64 years of age from the greater New York area recorded between 2006- 2016 were collated including demographic and traditional sleep scoring metrics. Studies where TST < 4 hours were removed. Demographic, sleep macrostructure, OSA (AHI4% & AHI3A criteria), pulse oximetry (SpO2) nadir and PLM measures were compared according to sex.
Results
PSGs from 1282 older adults (average age 70 years in both sexes, 41% female) were included in the analyses. Women had a significantly greater SWS% (14.5 vs 7.9, p<0.001) and less N1% (18.2 vs 24.4, p<0.001), without significant differences in TST, N2%, REM%, sleep efficiency or SpO2 nadir. Men had significantly higher all-sleep OSA (median AHI4% 8.8 vs 11.1, p=0.0004; median AHI3A 24.4 vs 27.9, p=0.003) and PLM’s (4.0 vs 7.6/hour, p=0.008) but women had significantly more OSA during REM sleep (median REM AHI4% 16.7 vs 14.0, p=0.01; median REM AHI3A 32.6 vs 27.4, p=0.0002). Inverse non-linear associations were observed between OSA severity and %SWS and %REM with a unique pattern for each sleep stage. The pattern between men and women within each stage appeared similar.
Conclusion
In this clinical sample of older adults, women exhibit a greater proportion of SWS and worse REM-related OSA then men. Increasing OSA severity is associated with non-linear reductions in %SWS and %REM, and we plan to further investigate these relationships and sexual dimorphism by using quantitative analysis of PSG signals for more precise measures of slow wave activity and breathing physiology than traditional sleep scoring metrics.
Support
R01AG056682
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Affiliation(s)
- A E Mullins
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - N Bagchi
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - A Parekh
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - K Kam
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Wang
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - M K Williams
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - D M Rapoport
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - I Ayappa
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - O E Burschtin
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - A W Varga
- Icahn School of Medicine at Mount Sinai, New York, NY
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D’Rozario AL, Kao C, Mullins AE, Memarian N, Yee B, Duffy S, Banerjee D, Cho G, Wong KK, Kremerskothen K, Chapman J, Haroutonian C, Bartlett DJ, Naismith SL, Grunstein RR. 0669 The Effects Of Continuous Positive Airway Pressure Therapy In Moderate To Severe Obstructive Sleep Apnea: A High-density EEG Study. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
A previous high-density electroencephalography (EEG) investigation in asymptomatic OSA showed regional deficits in sleep EEG power particularly slow wave activity (SWA) during NREM sleep in the parietal region. It is unclear whether treatment with CPAP can reverse local sleep EEG abnormalities in OSA, and whether any recovery is related to improvement in sleep-dependent memory consolidation.
Methods
Fifteen male participants (age 50.4±6.5yrs, AHI 51.7±23.5/h) with moderate-severe OSA (AHI>15/h) underwent overnight polysomnography with 256-channel high-density EEG at baseline and following 3 months of CPAP therapy. A word paired associates declarative memory task was administered before and after sleep. After artefact removal, spectral analysis was performed for all channels. Topographical power maps were calculated for standard frequency ranges for NREM sleep (164 channels within a 0.57 radius from the vertex). Maps were compared using both absolute and normalized power (z-scores computed for each subject) and differences between baseline and treatment were determined by statistical nonparametric mapping.
Results
In 11 CPAP compliant patients (intolerant of CPAP [n=3]/high-density EEG [n=1]), analysis of polysomnographic variables showed that total sleep time did not differ but N1 (baseline vs. treatment: 66.9 vs. 39.5 mins,p=0.008) and N2 (195.0 vs. 150.6 mins,p=0.002) sleep was lower and N3 (89.8 vs. 128.7 mins,p=0.003) was higher after CPAP. Topographic analysis of high-density EEG data revealed a regional increase in SWA (1-4.5Hz) EEG power during N3 sleep in a cluster of electrodes overlying the centro-parietal cortex (cluster mean t-value=2.87,p=0.02). The change in overnight declarative memory consolidation (% recognition) after CPAP was significantly correlated with the change in slow spindle frequency activity in frontal regions (cluster mean r=0.875,p=0.003).
Conclusion
CPAP treatment may enhance localised deficits in sleep EEG activity in OSA, and specific regional recovery may translate to memory improvements in the short-term. These data also highlight the potential for long-term therapeutic effects on cognitive outcomes in OSA.
Support
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Affiliation(s)
- A L D’Rozario
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - C Kao
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - A E Mullins
- Icahn School of Medicine, Mount Sinai, New York City, New York, USA
| | - N Memarian
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - B Yee
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - S Duffy
- Faculty of Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - D Banerjee
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - G Cho
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - K K Wong
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - K Kremerskothen
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - J Chapman
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - C Haroutonian
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - D J Bartlett
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - S L Naismith
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - R R Grunstein
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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Bubu OM, Mbah AK, Williams NJ, Turner AD, Parekh A, Mullins AE, Kam K, Umasabor-Bubu OQ, Varga AW, Rapoport DM, Ayappa I, Jean-Louis G, Osorio RS. 1153 Association Of Nocturnal Sleep Disturbance And Prospective Cognitive Decline In Cognitive Normal Elderly: Findings From The National Alzheimer’s Coordinating Center Uniform Dataset. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
We determined whether nocturnal sleep disturbance (NSD) is associated with prospective cognitive decline in clinically normal older adults
Methods
Prospective longitudinal study utilizing data from the National Alzheimer’s Coordinating Center (NACC) Uniform Data set (UDS). NSD data, as characterized by the Neuropsychiatric Inventory Questionnaire (NPI-Q), were derived from 10,600 participants at baseline, with at least one UDS follow-up visit, from 32 National Institute of Aging Alzheimer’s Disease Research Centers (ADRC). Prospective cognitive decline was characterized as incident mild cognitive impairment (MCI) diagnosis during UDS follow-up. Logistic mixed-effects model with random intercept and slope examined associations between the NSD and longitudinal cognitive decline. All models included age at baseline, sex, years of education, APOE ε4 status and their interactions with time. Time was operationalized as years from baseline for each participant.
Results
Of the 10,600 cognitively normal participants at baseline, 1,017 (8.6%) had NSD. The proportion of males versus females with sleep problems was 10.1% vs. 9.3% respectively. For participants with NSD and no NSD, the mean (SD) age was 71 (7.3) and 70 (5.7) years and average follow-up time was 5.2 (2.6) and 4.9 (2.7) years, respectively. Participants with NSD were significantly more likely to develop incident MCI during UDS follow-up (OR: 1.42, p =.003). The interaction of NSD with time was significant (p< .001) suggesting an increase in the likelihood of conversion to MCI increased over time. Furthermore, there were significant differences in mean conversion rates to MCI in the NSD group when the previous time-point was compared to the next (p<01), with a time dependent dose response in the risk of conversion to MCI observed.
Conclusion
In elderly cognitive-normal individuals, nocturnal sleep disturbance is associated with a time-dependent progression risk to MCI. These findings are consistent with the role of disturbed sleep in the development of Alzheimer’s Disease.
Support
NIH/NIA/NHLBI (L30-AG064670, CIRAD P30AG059303 Pilot, T32HL129953, R01HL118624, R21AG049348, R21AG055002, R01AG056031, R01AG022374, R21AG059179, R01AG056682, R01AG056531, K07AG05268503, K23HL125939)
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Affiliation(s)
- O M Bubu
- NYU School of Medicine, New York, NY
| | - A K Mbah
- University of South Florida, Tampa, FL
| | | | | | - A Parekh
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - A E Mullins
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - K Kam
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - A W Varga
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - D M Rapoport
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - I Ayappa
- Icahn School of Medicine at Mount Sinai, New York, NY
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15
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Parekh A, Mullins AE, Kam K, Varga AW, Rapoport DM, Ayappa I. Slow-wave activity surrounding stage N2 K-complexes and daytime function measured by psychomotor vigilance test in obstructive sleep apnea. Sleep 2020; 42:5250905. [PMID: 30561750 DOI: 10.1093/sleep/zsy256] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/20/2018] [Accepted: 12/14/2018] [Indexed: 01/12/2023] Open
Abstract
STUDY OBJECTIVE To better understand the inter-individual differences in neurobehavioral impairment in obstructive sleep apnea (OSA) and its treatment with continuous positive airway pressure (CPAP), we examined how changes in sleep electroencephalography (EEG) slow waves were associated with next-day psychomotor vigilance test (PVT) performance. METHODS Data from 28 OSA subjects (Apnea-Hypopnea Index with 3% desaturation and/or with an associated arousal [AHI3A] > 15/hour; AHI3A = sum of all apneas and hypopneas with 3% O2 desaturation and/or an EEG arousal, divided by total sleep time [TST]), who underwent three full in-lab nocturnal polysomnographies (NPSGs: chronic OSA, CPAP-treated OSA, and acute OSA), and 19 healthy sleepers were assessed. Four 20-minute PVTs were performed after each NPSG along with subjective and objective assessment of sleepiness. Three EEG metrics were calculated: K-complex (KC) Density (#/minute of N2 sleep), change in slow-wave activity in 1-second envelopes surrounding KCs (ΔSWAK), and relative frontal slow-wave activity during non-rapid eye movement (NREM) (%SWA). RESULTS CPAP treatment of OSA resulted in a decrease in KC Density (chronic: 3.9 ± 2.2 vs. treated: 2.7 ± 1.1; p < 0.01; mean ± SD) and an increase in ΔSWAK (chronic: 2.6 ± 2.3 vs. treated: 4.1 ± 2.4; p < 0.01) and %SWA (chronic: 20.9 ± 8.8 vs. treated: 26.6 ± 8.6; p < 0.001). Cross-sectionally, lower ΔSWAK values were associated with higher PVT Lapses (chronic: rho = -0.55, p < 0.01; acute: rho = -0.46, p = 0.03). Longitudinally, improvement in PVT Lapses with CPAP was associated with an increase in ΔSWAK (chronic to treated: rho = -0.48, p = 0.02; acute to treated: rho = -0.5, p = 0.03). In contrast, OSA severity or global sleep quality metrics such as arousal index, NREM, REM, or TST were inconsistently associated with PVT Lapses. CONCLUSION Changes in EEG slow waves, in particular ∆SWAK, explain inter-individual differences in PVT performance better than conventional NPSG metrics, suggesting that ΔSWAK is a night-time correlate of next-day vigilance in OSA.
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Affiliation(s)
| | - Anna E Mullins
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Korey Kam
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew W Varga
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David M Rapoport
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Indu Ayappa
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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16
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Gilat M, Coeytaux Jackson A, Marshall NS, Hammond D, Mullins AE, Hall JM, Fang BAM, Yee BJ, Wong KKH, Grunstein RR, Lewis SJG. Melatonin for rapid eye movement sleep behavior disorder in Parkinson's disease: A randomised controlled trial. Mov Disord 2019; 35:344-349. [PMID: 31674060 PMCID: PMC7027846 DOI: 10.1002/mds.27886] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/13/2019] [Accepted: 09/15/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Melatonin may reduce REM-sleep behavior disorder (RBD) symptoms in Parkinson's disease (PD), though robust clinical trials are lacking. OBJECTIVE To assess the efficacy of prolonged-release (PR) melatonin for RBD in PD. METHODS Randomized, double-blind, placebo-controlled, parallel-group trial with an 8-week intervention and 4-week observation pre- and postintervention (ACTRN12613000648729). Thirty PD patients with rapid eye movement sleep behavior disorder were randomized to 4 mg of prolonged-release melatonin (Circadin) or matched placebo, ingested orally once-daily before bedtime. Primary outcome was the aggregate of rapid eye movement sleep behavior disorder incidents averaged over weeks 5 to 8 of treatment captured by a weekly diary. Data were included in a mixed-model analysis of variance (n = 15 per group). RESULTS No differences between groups at the primary endpoint (3.4 events/week melatonin vs. 3.6 placebo; difference, 0.2; 95% confidence interval = -3.2 to 3.6; P = 0.92). Adverse events included mild headaches, fatigue, and morning sleepiness (n = 4 melatonin; n = 5 placebo). CONCLUSION Prolonged-release melatonin 4 mg did not reduce rapid eye movement sleep behavior disorder in PD. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Moran Gilat
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, The University of Sydney, Sydney, Australia.,Research Group for Neurorehabilitation (eNRGy), Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Alessandra Coeytaux Jackson
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Department of Neurology, University Hospitals of Geneva, Switzerland
| | - Nathaniel S Marshall
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Deborah Hammond
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, The University of Sydney, Sydney, Australia
| | - Anna E Mullins
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Julie M Hall
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, The University of Sydney, Sydney, Australia
| | - Bernard A M Fang
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Brendon J Yee
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Keith K H Wong
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ron R Grunstein
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Simon J G Lewis
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, The University of Sydney, Sydney, Australia
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Mullins AE, Williams MK, Kam K, Parekh A, Castillo B, Rapoport DM, Ayappa I, Osorio RS, Varga AW. 0293 Effects of Obstructive Sleep Apnea on Human Spatial Navigational Memory Processing in Cognitively Normal Older Adults. Sleep 2019. [DOI: 10.1093/sleep/zsz067.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anna E Mullins
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Masrai K Williams
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Korey Kam
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ankit Parekh
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bresne Castillo
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M Rapoport
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Indu Ayappa
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ricardo S Osorio
- Department of Psychiatry, NYU School of Medicine, New York, NY, USA
| | - Andrew W Varga
- Mount Sinai Integrative Sleep Center, Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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Poon JJY, Chapman JL, Wong KKH, Mullins AE, Cho G, Kim JW, Yee BJ, Grunstein RR, Marshall NS, D'Rozario AL. Intra-individual stability of NREM sleep quantitative EEG measures in obstructive sleep apnea. J Sleep Res 2019; 28:e12838. [PMID: 30821056 DOI: 10.1111/jsr.12838] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/23/2019] [Accepted: 02/04/2019] [Indexed: 01/31/2023]
Abstract
Electroencephalography is collected routinely during clinical polysomnography, but is often utilised to simply determine sleep time to calculate apnea-hypopnea indices. Quantitative analysis of these data (quantitative electroencephalogram) may provide trait-like information to predict patient vulnerability to sleepiness. Measurements of trait-like characteristics need to have high test-retest reliability. We aimed to investigate the intra-individual stability of slow-wave (delta power) and spindle frequency (sigma power) activity during non-rapid eye movement sleep in patients with obstructive sleep apnea. We recorded sleep electroencephalograms during two overnight polysomnographic recordings in 61 patients with obstructive sleep apnea (median days between studies 47, inter-quartile range 53). Electroencephalograms recorded at C3-M2 derivation were quantitatively analysed using power spectral analysis following artefact removal. Relative delta (0.5-4.5 Hz) and sigma (12-15 Hz) power during non-rapid eye movement sleep were calculated. Intra-class correlation coefficients and Bland-Altman plots were used to assess agreement between nights. Intra-class correlation coefficients demonstrated good-to-excellent agreement in the delta and sigma frequencies between nights (intra-class correlation coefficients: 0.84, 0.89, respectively). Bland-Altman analysis of delta power showed a mean difference close to zero (-0.4, 95% limits of agreement -9.4, 8.7) and no heteroscedasticity with increasing power. Sigma power demonstrated heteroscedasticity, with reduced stability as sigma power increased. The mean difference of sigma power between nights was close to zero (0.1, 95% limits -1.6, 1.8). We have demonstrated the stability of slow-wave and spindle frequency electroencephalograms during non-rapid eye movement sleep within patients with obstructive sleep apnea. The electroencephalogram profile during non-rapid eye movement sleep may be a useful biomarker for predicting vulnerability to daytime impairment in obstructive sleep apnea and responsiveness to treatment.
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Affiliation(s)
- Joseph J Y Poon
- Sydney Medical School, University of Sydney, Sydney, Australia.,CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Julia L Chapman
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,Sydney Local Health District, Sydney, Australia
| | - Keith K H Wong
- Sydney Medical School, University of Sydney, Sydney, Australia.,CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Anna E Mullins
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,University of Sydney Nursing School, Sydney, Australia
| | - Garry Cho
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jong W Kim
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Department of Healthcare IT, Inje University, Inje-ro 197, Kimhae, Kyunsangnam-do, South Korea
| | - Brendon J Yee
- Sydney Medical School, University of Sydney, Sydney, Australia.,CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ronald R Grunstein
- Sydney Medical School, University of Sydney, Sydney, Australia.,CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nathaniel S Marshall
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,University of Sydney Nursing School, Sydney, Australia
| | - Angela L D'Rozario
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,NeuroSleep, NHMRC Centre of Research Excellence, Sydney, Australia.,School of Psychology, University of Sydney, Sydney, Australia
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19
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Kam K, Parekh A, Sharma RA, Andrade A, Lewin M, Castillo B, Bubu OM, Chua NJ, Miller MD, Mullins AE, Glodzik L, Mosconi L, Gosselin N, Prathamesh K, Chen Z, Blennow K, Zetterberg H, Bagchi N, Cavedoni B, Rapoport DM, Ayappa I, de Leon MJ, Petkova E, Varga AW, Osorio RS. Sleep oscillation-specific associations with Alzheimer's disease CSF biomarkers: novel roles for sleep spindles and tau. Mol Neurodegener 2019; 14:10. [PMID: 30791922 PMCID: PMC6385427 DOI: 10.1186/s13024-019-0309-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Based on associations between sleep spindles, cognition, and sleep-dependent memory processing, here we evaluated potential relationships between levels of CSF Aβ42, P-tau, and T-tau with sleep spindle density and other biophysical properties of sleep spindles in a sample of cognitively normal elderly individuals. METHODS One-night in-lab nocturnal polysomnography (NPSG) and morning to early afternoon CSF collection were performed to measure CSF Aβ42, P-tau and T-tau. Seven days of actigraphy were collected to assess habitual total sleep time. RESULTS Spindle density during NREM stage 2 (N2) sleep was negatively correlated with CSF Aβ42, P-tau and T-tau. From the three, CSF T-tau was the most significantly associated with spindle density, after adjusting for age, sex and ApoE4. Spindle duration, count and fast spindle density were also negatively correlated with T-tau levels. Sleep duration and other measures of sleep quality were not correlated with spindle characteristics and did not modify the associations between sleep spindle characteristics and the CSF biomarkers of AD. CONCLUSIONS Reduced spindles during N2 sleep may represent an early dysfunction related to tau, possibly reflecting axonal damage or altered neuronal tau secretion, rendering it a potentially novel biomarker for early neuronal dysfunction. Given their putative role in memory consolidation and neuroplasticity, sleep spindles may represent a mechanism by which tau impairs memory consolidation, as well as a possible target for therapeutic interventions in cognitive decline.
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Affiliation(s)
- Korey Kam
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Ankit Parekh
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Ram A. Sharma
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Andreia Andrade
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Monica Lewin
- Nathan Kline Institute for Psychiatric Research, Orangeburg, NY 10962 USA
| | - Bresne Castillo
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Omonigho M. Bubu
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Nicholas J. Chua
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Margo D. Miller
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Anna E. Mullins
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Lidia Glodzik
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Lisa Mosconi
- Department of Neurology, Weill Cornell Medical College, New York, NY USA
| | - Nadia Gosselin
- Center for Advanced Research in Sleep Medicine (CARSM), Department of Psychology, Hospital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada and Université de Montreal, Montreal, Quebec Canada
| | | | - Zhe Chen
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Kaj Blennow
- Institute of Neuroscience and Psychiatry, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Psychiatry, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
| | - Nisha Bagchi
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Bianca Cavedoni
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - David M. Rapoport
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Indu Ayappa
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Mony J. de Leon
- Nathan Kline Institute for Psychiatric Research, Orangeburg, NY 10962 USA
| | - Eva Petkova
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
- Child and Adolescent Psychiatry, NYU School of Medicine, New York, NY 10016 USA
| | - Andrew W. Varga
- Mount Sinai Integrative Sleep Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA
| | - Ricardo S. Osorio
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016 USA
- Nathan Kline Institute for Psychiatric Research, Orangeburg, NY 10962 USA
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20
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Chapman J, Poon J, Wong KK, Mullins AE, Cho G, Yee BJ, Kim J, Grunstein RR, Marshall NS, D’Rozario A. 0452 Intra-individual Stability of Quantitative EEG as a Biomarker in Obstructive Sleep Apnea. Sleep 2018. [DOI: 10.1093/sleep/zsy061.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Chapman
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- Sydney Local Health District, Sydney, AUSTRALIA
| | - J Poon
- University of Sydney Medical School, Sydney, AUSTRALIA
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
| | - K K Wong
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia, Sydney, AUSTRALIA
| | - A E Mullins
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- University of Sydney Nursing School, Sydney, AUSTRALIA
| | - G Cho
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
| | - B J Yee
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia, Sydney, AUSTRALIA
| | - J Kim
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
| | - R R Grunstein
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia, Sydney, AUSTRALIA
| | - N S Marshall
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- University of Sydney Nursing School, Sydney, AUSTRALIA
| | - A D’Rozario
- Woolcock Institute of Medical Research/University of Sydney, Missenden Road, AUSTRALIA
- University of Sydney School of Psychology, Sydney, AUSTRALIA
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21
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Mullins AE, Bolitho SJ, Terpening Z, D’Rozario AL, Kim JW, Melehan KL, Marshall NS, Grunstein RR, Naismith SL, Lewis SJ. 1158 REDUCED SLEEP SPINDLE ACTIVITY IN PARKINSON’S DISEASE IS ASSOCIATED WITH NEUROPSYCHOLOGICAL IMPAIRMENT. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.1157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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22
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Miller CB, Bartlett DJ, Mullins AE, Dodds KL, Gordon CJ, Kyle SD, Kim JW, D'Rozario AL, Lee RSC, Comas M, Marshall NS, Yee BJ, Espie CA, Grunstein RR. Clusters of Insomnia Disorder: An Exploratory Cluster Analysis of Objective Sleep Parameters Reveals Differences in Neurocognitive Functioning, Quantitative EEG, and Heart Rate Variability. Sleep 2016; 39:1993-2004. [PMID: 27568796 DOI: 10.5665/sleep.6230] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/23/2016] [Indexed: 02/01/2023] Open
Abstract
STUDY OBJECTIVES To empirically derive and evaluate potential clusters of Insomnia Disorder through cluster analysis from polysomnography (PSG). We hypothesized that clusters would differ on neurocognitive performance, sleep-onset measures of quantitative (q)-EEG and heart rate variability (HRV). METHODS Research volunteers with Insomnia Disorder (DSM-5) completed a neurocognitive assessment and overnight PSG measures of total sleep time (TST), wake time after sleep onset (WASO), and sleep onset latency (SOL) were used to determine clusters. RESULTS From 96 volunteers with Insomnia Disorder, cluster analysis derived at least two clusters from objective sleep parameters: Insomnia with normal objective sleep duration (I-NSD: n = 53) and Insomnia with short sleep duration (I-SSD: n = 43). At sleep onset, differences in HRV between I-NSD and I-SSD clusters suggest attenuated parasympathetic activity in I-SSD (P < 0.05). Preliminary work suggested three clusters by retaining the I-NSD and splitting the I-SSD cluster into two: I-SSD A (n = 29): defined by high WASO and I-SSD B (n = 14): a second I-SSD cluster with high SOL and medium WASO. The I-SSD B cluster performed worse than I-SSD A and I-NSD for sustained attention (P ≤ 0.05). In an exploratory analysis, q-EEG revealed reduced spectral power also in I-SSD B before (Delta, Alpha, Beta-1) and after sleep-onset (Beta-2) compared to I-SSD A and I-NSD (P ≤ 0.05). CONCLUSIONS Two insomnia clusters derived from cluster analysis differ in sleep onset HRV. Preliminary data suggest evidence for three clusters in insomnia with differences for sustained attention and sleep-onset q-EEG. CLINICAL TRIAL REGISTRATION Insomnia 100 sleep study: Australia New Zealand Clinical Trials Registry (ANZCTR) identification number 12612000049875. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347742.
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Affiliation(s)
- Christopher B Miller
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Medical School, University of Sydney, Australia
| | - Delwyn J Bartlett
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Medical School, University of Sydney, Australia
| | - Anna E Mullins
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Nursing School, University of Sydney, Australia
| | - Kirsty L Dodds
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Nursing School, University of Sydney, Australia
| | - Christopher J Gordon
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Nursing School, University of Sydney, Australia
| | - Simon D Kyle
- Nuffield Department of Clinical Neurosciences and Sleep & Circadian Neuroscience Institute, University of Oxford, UK
| | - Jong Won Kim
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia
| | - Angela L D'Rozario
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Medical School, University of Sydney, Australia.,Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, NSW, Australia
| | - Rico S C Lee
- Clinical Research Unit, Brain & Mind Centre, University of Sydney, Australia
| | - Maria Comas
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia
| | - Nathaniel S Marshall
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Nursing School, University of Sydney, Australia
| | - Brendon J Yee
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Medical School, University of Sydney, Australia.,Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, NSW, Australia
| | - Colin A Espie
- Nuffield Department of Clinical Neurosciences and Sleep & Circadian Neuroscience Institute, University of Oxford, UK
| | - Ronald R Grunstein
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia.,Sydney Medical School, University of Sydney, Australia.,Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, NSW, Australia
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Miller CB, Kyle SD, Gordon CJ, Espie CA, Grunstein RR, Mullins AE, Postnova S, Bartlett DJ. Physiological Markers of Arousal Change with Psychological Treatment for Insomnia: A Preliminary Investigation. PLoS One 2015; 10:e0145317. [PMID: 26683607 PMCID: PMC4689577 DOI: 10.1371/journal.pone.0145317] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/30/2015] [Indexed: 01/04/2023] Open
Abstract
Objectives The aim of this preliminary study was to evaluate if Sleep Restriction Therapy for insomnia is associated with modifications to physiological arousal, indexed through overnight measures of plasma cortisol concentrations and core body temperature. Methods In a pre-to-post open label study design, eleven patients with chronic and severe Psychophysiological Insomnia underwent 5 weeks of Sleep Restriction Therapy. Results Eight (73%) patients out of 11 consented completed therapy and showed a decrease in insomnia severity pre-to-post treatment (mean (SD): 18.1 (2.8) versus 8.4 (4.8); p = .001). Six patients were analyzed with pre-to-post overnight measures of temperature and cortisol. Contrary to our hypothesis, significantly higher levels of plasma cortisol concentrations were found during the early morning at post-treatment compared to baseline (p < .01), while no change was observed in the pre-sleep phase or early part of the night. Core body temperature during sleep was however reduced significantly (overall mean [95% CI]: 36.54 (°C) [36.3, 36.8] versus 36.45 [36.2, 36.7]; p < .05). Conclusions Sleep Restriction Therapy therefore was associated with increased early morning cortisol concentrations and decreased core body temperature, supporting the premise of physiological changes in functioning after effective therapy. Future work should evaluate change in physiological variables associated with clinical treatment response. Trial Registration Australian New Zealand Clinical Trials Registry ANZCTR 12612000049875
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Affiliation(s)
- Christopher B. Miller
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- * E-mail:
| | - Simon D. Kyle
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Christopher J. Gordon
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Colin A. Espie
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Ronald R. Grunstein
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, Australia
| | - Anna E. Mullins
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Delwyn J. Bartlett
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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24
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Mullins AE. Carotid-cavernous Arteriovenous Fistula. Proc R Soc Med 1963; 56:1105. [PMID: 19994308 PMCID: PMC1897755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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