Background
Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.
Aim
...Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology to critically evaluate the evidence regarding potential links and the impact of therapy.
Materials and methods
Thirteen research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta‐analyses; second, primary studies post‐dating the systematic reviews/meta‐analyses. A total of 445 studies were evaluated and 88 were included. Statements were generated regarding current evidence and clinical practice.
Results
Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle‐aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment‐compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, whilst CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, whilst the pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post‐stroke insomnia and RLS and their association with a less favourable stroke outcome, whilst treatment data are scarce.
Discussion/Conclusion
Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.
Pregnancy is a risk factor for transient restless legs syndrome, which usually recovers during the postdelivery period. The goal of the present survey is to investigate whether restless legs syndrome ...during pregnancy represents a risk factor for later development of restless legs syndrome.
A long-term follow-up study, planned as an extension of a previous survey on restless legs syndrome during pregnancy, was carried out. After a mean interval of 6.5 years, 207 parous women were contacted again to compare the incidence of restless legs syndrome among subjects who never experienced the symptoms with those who reported restless legs syndrome during the previously investigated pregnancy.
Seventy-four women who experienced restless legs syndrome during previous pregnancy, and 133 who did not, were included in the study. The incidence of restless legs syndrome was 56% person/year in women who experienced the transient pregnancy restless legs syndrome form, and 12.6% person/year in subjects who did not, with a significant 4-fold increased risk of developing chronic restless legs syndrome in women who presented restless legs in the previous pregnancy. Considering further new pregnancies during the follow-up period, the restless legs symptoms reappeared in 58% of the cases, while they emerged for the first time in only 3% of women who had never experienced restless legs syndrome.
The transient pregnancy restless legs syndrome form is a significant risk factor for the development of a future chronic idiopathic restless legs syndrome form, and for a new transient symptomatology in a future pregnancy.
Background and purpose
Isolated rapid eye movement sleep behaviour disorder (iRBD) is a parasomnia, recently recognized as a risk factor for progression to Parkinson's disease, dementia with Lewy ...body and multiple system atrophy. Biomarker studies in iRBD are relevant due to lack of evidence in this condition. The identification of biomarkers able to predict progression to synucleinopathy diseases is critical for iRBD. Fluorodeoxyglucose‐positron emission tomography (FDG‐PET) imaging might provide information about ongoing neurodegenerative processes. In the present study, we tested for presence of brain hypometabolism patterns as biomarkers of neurodegeneration in single iRBD individuals.
Methods
We recruited 37 subjects with polysomnography‐confirmed iRBD, with neuropsychological assessment and available FDG‐PET scan. Images were analysed with a validated statistical parametric mapping procedure, providing individual hypometabolism maps.
Results
According to the neuropsychological evaluation, 22 subjects with iRBD had normal cognition and 15 subjects showed impairments, particularly in visuoperceptive/visuospatial and memory domains. One‐fifth of the cases were impaired on the Qualitative Scoring of Pentagon Test. In 32 iRBD cases, FDG‐PET statistical parametric maps revealed significant cerebral hypometabolism, namely in the occipital lobes (n = 5), occipital and cerebellar regions (n = 13), occipitoparietal regions (n = 13) and a selective cerebellar hypometabolism (n = 1). Five cases had normal FDG‐PET scans.
Conclusions
These imaging findings indicate that brain neurodegenerative processes are present and already detectable in iRBD. The different hypometabolism patterns in the single individuals may reflect specific early pathophysiological events due to the underlying synucleinopathy, with a specific neural vulnerability for the occipital cortex that might pre‐date a risk of progression towards dementia with Lewy body.
Abstract This report presents the results of the work by a joint task force of the International and European Restless Legs Syndrome Study Groups and World Association of Sleep Medicine that revised ...and updated the current standards for recording and scoring leg movements (LM) in polysomnographic recordings (PSG). First, the background of the decisions made and the explanations of the new rules are reported and then specific standard rules are presented for recording, detecting, scoring and reporting LM activity in PSG. Each standard rule has been classified with a level of evidence. At the end of the paper, Appendix 1 provides algorithms to aid implementation of these new standards in software tools. There are two main changes introduced by these new rules: 1) Candidate LM (CLM), are any monolateral LM 0.5-10 s long or bilateral LM 0.5-15 s long; 2) periodic LM (PLM) are now defined by runs of at least 4 consecutive CLM with an intermovement interval ≥10 and ≤90 s without any CLM preceded by an interval <10 s interrupting the PLM series. There are also new options defining LM associated with respiratory events. The PLM rate may now first be determined for all CLM not excluding any related to respiration (providing a consistent number across studies regardless of the rules used to define association with respiration) and, subsequently, the PLM rate should also be calculated without considering the respiratory related events. Finally, special considerations for pediatric studies are provided. The expert visual scoring of LM has only been altered by the new standards to require accepting all LM >0.5 s regardless of duration, otherwise the technician scores the LM as for the old standards. There is a new criterion for the morphology of LM that applies only to computerized LM detection to better match expert visual detection. Available automatic scoring programs will incorporate all the new rules so that the new standards should reduce technician burden for scoring PLMS.
Insomnia is a frequent symptom in depressed patients. It can present with difficulty in initiating and/or maintaining sleep. We retrospectively evaluated a group of 15 patients affected by major ...depressive disorder and complaining of insomnia, who started vortioxetine (VOR) treatment for their depressive symptoms. The following questionnaires were captured at baseline and follow‐up: Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and Beck Depression Inventory. Pittsburgh Sleep Quality Index total score significantly decreased between follow‐up and baseline (P < 0.01), and in several subitems related to sleep quality and continuity. Moreover, Epworth Sleepiness Scale decreased between follow‐up and baseline (P < 0.01). Finally, Beck Depression Inventory reduction was also evident between follow‐up and baseline (P < 0.01). This retrospective analysis showing the significant effect of VOR on both depressive symptoms and insomnia in patients showing comorbid major depressive disorder and insomnia invites further research in order to confirm this preliminary evidence. We hypothesize that the VOR mechanism of action may explain the improvement of subjective sleep, other than depressive symptoms.
Background. Sleep complaints are common health issues in the general population. These conditions are associated with poorer physical and psychological activity, and they may have important social, ...economic, and personal consequences. In the last years, several food supplements with different plant extracts have been developed and are currently taken for improving sleep. Study Objectives. The aim of this study is to systematically review recent literature on oral plant extracts acting on sleep disorders distinguishing their action on the different symptoms of sleep complaints: difficulty in initiating or maintaining sleep, waking up too early, and quality of sleep. Methods. We searched the PubMed database up to 05/03/2020 based on data from randomized, double-blind, placebo-controlled trials, noncontrolled trials, and cohort studies conducted in children and adult subjects. The search words used contained the following terms: oral food supplement and sleep disorders and the like. The most studied compounds were further analyzed with a second search using the following terms: name of the compound and sleep disorders. We selected 7 emerging compounds and 38 relevant reports. Results. Although nutraceutical natural products have been used for sleep empirically, there is a scarcity of evidence on the efficacy of each product in clinical studies. Valerian and lavender were the most frequently studied plant extracts, and their use has been associated (with conflicting results) with anxiolytic effects and improvements in quality and duration of sleep. Conclusions. Sleep aids based on plant extracts are generally safe and well tolerated by the population. More high-quality research is needed to confirm the effectiveness of food supplements containing plant extracts in sleep complaints; in particular, it would be interesting to evaluate the association between plant extracts and sleep hygiene guidelines and to identify the optimal products to be used in a specific symptom of sleep complaint, giving more appropriate tools to the medical doctor.
Sleep-related disorders have been reported to have a higher prevalence in multiple sclerosis (MS) than in the general population. They are often undervalued for the presence of more severe physical ...problems and the occurrence at night, without a direct observation in common clinical practice, but if not recognized and treated they can negatively affect the quality of life causing daytime drowsiness and worsening fatigue. Sleep related disorders most commonly reported in MS are as follows: insomnia, sleep-related breathing disorders (SRBD), restless legs syndrome (RLS) and periodic limb movement disorders (PLMD). Secondary narcolepsy, REM sleep behavior disorder (RBD) and propriospinal myoclonus have been also described in some case reports or series. The purpose of this review is to correlate the more common sleep disturbances in MS patients to the involvement of specific brain regions, analyzing their relationship with MRI findings. While insomnia is usually secondary to other disabling symptoms such as nocturia or pain, SRBD, RLS, narcolepsy, RBD and propriospinal myoclonus in MS patients can be the consequence of an injury of specific central nervous system (CNS) areas. Lesions in the pontine tegmentum and the dorsal medulla have been associated with SRBD, spinal cord lesions or atrophy with RLS, bilateral lesions in the lateral hypothalamus with narcolepsy-like symptoms, lesions in the dorsal pontine tegmentum with RBD and intramedullary demyelinating plaques in spinal cord with propriospinal myoclonus. MS specialists and general neurologists should be aware of these comorbidities since neuroimaging, which is routinely performed in MS, could provide helpful clinical indications on patients with secondary sleep-related disorders and to categorize symptomatic patients who need to underdo more in-depth sleep studies.
•Insomnia, SRBD, RLS and PLMD have a higher prevalence in MS patients.•Narcolepsy, RBD and propriospinal myoclonus have been reported in some case reports.•Sleep disorders in MS can arise from damage to specific CNS areas.•MRI could provide helpful indications on MS patients with sleep disorders.
Abstract
Introduction
Several studies investigated the role of objective sleep markers, in particular of Total Sleep Time (TST) in identifying different subtypes of Insomnia Disorder (ID) and in ...evaluating the efficacy of treatments. Based on objective TST two phenotypes of ID are usually distinguished in the literature: normal sleepers (objective sleep duration ≥ 6 hours) and short sleepers (objective sleep duration < 6 hours). Aim of our study was to evaluate in normal and short sleepers (objective sleep duration was assessed by both Polysomnography and Actigraphy) possible different response to Cognitive-Behavioral Therapy for Insomnia (CBT-I).
Methods
53 ID patients (females = 50.9%; mean age = 56.53±11.43) were divided into “Short Sleep duration” and “Normal Sleep duration” groups. All patients underwent 7-sessions group CBT-I. Main clinical outcome was Insomnia Severity Index questionnaire (ISI); secondary outcomes were Sleep Efficacy (SE), Sleep Latency (SL), Wake After Sleep Onset (WASO), Number of Awakenings (N°awk) according to sleep diaries.
Results
All ID patients showed significant improvements after treatment for all clinical outcomes. Non-significant effects of CBT-I between “Short Sleep duration” and “Normal Sleep duration” measured by patients were found in terms of ISI, SE, SL, WASO and N°awk, neither using Polysomnography nor Actigraphy. Furthermore, no accordance between these two objective measurements was found for the identification of the two subgroups.
Conclusion
Our findings suggest that the use of objective TST (both by Actigraphy and Polysomnography) is not a consistent predictor for CBT-I effectiveness. Moreover, only a small percentage of patients were classified as short or normal sleepers according both to Polysomnography and Actigraphy. These findings underline the instability and poor reliability of using objective TST in subtyping insomniacs.
Support
No
Abstract
Introduction
Obstructive sleep apnea (OSA) is associated with cognitive deficits in vigilance, attention, and executive functions (EFs). To date, the mechanisms that characterize the ...impairment cognition in OSA remain partially uncertain. The dominant theories have mostly concentrated on hypoxia/hypercarbia, and sleep disruption and consequent excessive daytime sleepiness. Moreover, hypoxemia affects global cognitive functioning, but it is not clear whether and how the severity of the disease influences the EFs.
Methods
The current study aimed at assessing the relationships among OSA severity, daytime sleepiness, and EFs and self-reported impulsivity in a sample of OSA subjects who were classified according to Apnea-Hypopnea Index (AHI) in mild/moderate OSA (AHI<30) or severe OSA (AHI≥30). All OSA participants were consecutively admitted to the Sleep Disorders Center of the San Raffaele Turro Hospital. After OSA assessment, patients were administered the Italian translation of the Psychology Experiment Building Language EFs tasks and the Epworth Sleepiness Scale (ESS) and UPPS-P Impulsive Behavior Scale (UPPS-P). Participants’ sleepiness was considered severe if a score of 10 or higher on the ESS was observed.
Results
Confirming and extending previous reports, daytime sleepiness affected both attention performance (U=239.00, p<.05; Vargha & Delaney A=0.66), and inhibition performance (U=199.00, p<.05; A=0.70). No effect of AHI was observed on both variables (U=326.00, p>.05; A=0.55; U=330.00, p>.05; A=0.53, respectively). Conversely, self-reported impulsivity was associated with OSA severity (U=30.50, p<.001; A=0.86), but not with daytime sleepiness (U=84, p>.05; A=0.63).
Conclusion
Our findings showed the importance of considering both OSA severity and sleepiness in order to better understand EFs and impulsivity related to OSA.
Support
none
Obstructive sleep apnea (OSA) has been associated with a broad range of neurocognitive difficulties. The current view is that the neurocognitive impairment in OSA is due to the adverse effects of ...sleep fragmentation and/or intermittent hypoxia. The overall picture of cognitive deficits in OSA is complex. On balance, there appears to be negative effects of OSA on cognition, most likely in the domains of attention/vigilance, verbal and visual delayed long-term memory, visuospatial/constructional abilities, and executive dysfunction. Continuous positive airway pressure (CPAP) is the most effective and widely used treatment of OSA. In the majority of studies of OSA patients treated with CPAP, attention/vigilance improved, but changes in global functioning, executive functioning, and memory improved in about half of the studies. This may be due, in part, to variability in study design and sampling methodology across studies.
Structural volume changes have been demonstrated in brain regions of OSA patients including areas that regulate memory and executive function (e.g., frontal cortex, anterior cingulate, and hippocampus). Growing evidence suggests that the OSA-related changes in brain morphology may improve with CPAP treatment. Neuroimaging studies performed during cognitive testing have provided insight into CPAP's effect on function of neuroanatomical circuits in the brain. Although neuroimaging can provide important insights into the structural and functional differences associated with OSA, one of the challenges is to interpret the findings in light of comorbid conditions that also cause neural injury. The purpose of this article is to provide a narrative review of the publications on cognition and neuroimaging in OSA before and after CPAP treatment.
•The overall picture of cognitive deficits in OSA is complex•CPAP improves attention/vigilance and, partially, memory in OSA patients•Structural changes in frontal cortex and hippocampus have been found in OSA.•The OSA-related changes in brain morphology may improve with CPAP
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