Effects of sleep-disordered breathing and hypertension on cognitive function in elderly adults.

Purpose: The prevalence of sleep-disordered breathing (SDB) increases with aging. SDB is a risk of hypertension, and both might lead to cognitive decline. However, the role of SDB and hypertension on the pathogenesis of age-related cognitive decline remains unclear. We examined the effects of these two diseases on cognitive function in elderly adults.Methods: Fifty-two elderly individuals (mean age, 69.6 ± 4.0 years) free from impairment in daily living activities participated in this study. Apnea/hypopnea index (AHI) and minimum oxygen saturation (SpO2) were assessed using a portable home monitoring device. We evaluated excessive daytime sleepiness with the Epworth sleepiness scale (ESS). Cognitive performance was assessed using the Wisconsin card sorting test (WCST), continuous performance test-Identical pairs (CPT-IP), and N-back task. Hypertension and diabetes mellitus were evaluated via questionnaire and blood pressure value.Results: The WCST category achievement was significantly lower in participants with minimum SpO2 <90% than those with minimum SpO2 ≥90%. The percentage of correct answer on the 0- and 1-back tasks was significantly lower in the hypertensives than normotensives. Minimum SpO2 was correlated with category achievement on the WCST. Multiple regression analysis including age, sex, body mass index, AHI, minimum SpO2, ESS, hypertension, and diabetes mellitus revealed that hypertension was the most significant factor for percentage correct answers on the 0- and 1-back tasks. There were no significant correlations between body mass index, ESS or diabetes mellitus and the parameters of WCST, CPT-IP, or N-back tasks.Conclusion: In elderly adults, nocturnal hypoxia and hypertension had a negative effect on cognitive function.

Non-REM sleep-disordered breathing affects performance on the psychomotor vigilance task.

PURPOSE: Although many studies have investigated the clinical importance of sleep apnea on rapid eye movement (REM) and non-REM (NREM) sleep, the relationship between behavioral performance and apneic events during different sleep phases remains unclear. In the present study, we sought to investigate the effect of sleep phase fragmentation due to sleep-disordered breathing (SDB) during REM and NREM on the vigilance and sustainability of attention based on psychomotor vigilance task (PVT) performance. METHODS: From a pool of subjects who underwent consecutive diagnostic polysomnography (PSG) for obstructive sleep apnea, 163 adult subjects with both REM and NREM sleep ≥ 30 min were enrolled for our study and performed a standardized 10-min PVT. The main outcome variables of the PVT were mean reaction time (RT), PVT Lapse count, and the slope of the reciprocal RT. Subjective sleepiness was measured using the Epworth Sleepiness Scale (ESS). RESULTS: After multivariate linear regression analysis with adjustment for age, sex, body mass index, and the apnea-hypopnea index (AHI) of the counterpart sleep phase, we found that AHI during NREM (AHINREM) compared to AHI during REM (AHIREM) was significantly associated with PVT lapses. CONCLUSIONS: Our results suggest that SDB during NREM has a significant impact on vigilance lapses compared to that of REM.

[Sleep health education for elderly people].

Successful aging is characterized by minimal age-associated loss of the physiological functions of sleep and circadian clock. Sleep health education is necessary to have normal, quality nighttime sleep and full daytime alertness. Elderly people show changes of sleep parameters, accompanied by increased napping. Many studies have reported that daytime sleepiness or napping in elderly people could have potentially serious effects such as dementia and life-style related diseases. The main topics of sleep health education for elderly people are as follows: Right knowledge of sleep mechanism, understanding the bad influence of excessive napping, the effects of light on the circadian rhythm and negative effects of caffeine, alcohol and television.

Prevalence of obstructive sleep apnea syndrome in Japanese elementary school children aged 6-8 years.

PURPOSE: We aimed to determine the prevalence of and the risk factors for obstructive sleep apnea syndrome (OSAS) in Japanese children aged 6-8 years. METHODS: The parents of 202 children aged 6-8 years who attended a single elementary school in Shiga, Japan, were requested to complete the Child and Adolescent Sleep Checklist (CASC) and perform home Type 3 portable monitoring of their children. By using the CASC data and monitor recordings, we estimated the prevalence of pediatric OSAS with the help of different diagnostic criteria and identified the risk factors associated with OSAS. RESULTS: Complete data were obtained from 170 of the 194 children whose parents participated in the study. The mean total apnea-hypopnea index and obstructive apnea hypopnea index were 1.4 ± 1.3 and 0.4 ± 0.6 h(-1), respectively, and central apnea was the most prevalent type of respiratory event, accounting for 70.4% of all events. The overall prevalence of OSAS ranged from 0.6% to 43.5%, depending on the cutoff value used, and was 3.5% when using International Criteria of Sleep Disorders version II (ICSD II) diagnostic criteria. The presence of tonsillar hypertrophy was the only parameter whose prevalence was significantly elevated in children with OSAS across all diagnostic criteria. CONCLUSIONS: The prevalence of pediatric OSAS varies according to the diagnostic criteria used, indicating the need for further research focusing on outcomes to define a clinically significant diagnostic threshold. The presence of tonsillar hypertrophy is an important risk factor in the development of pediatric OSAS.

Obstructive sleep apnea in Asian primary school children.

PURPOSE: The objectives of this study were to examine the prevalence of obstructive sleep apnea (OSA) in primary school children, relationships between OSA and tonsillar hypertrophy, adenoid, and patency of the nasal cavity, and the effects of the tonsillar hypertrophy and adenoid on the nasal patency. METHODS: An examination of the palatine tonsils and anterior rhinoscopy, completion of a questionnaire survey, a measurement of nasal resistance, an examination for sleep apnea at home using portable polysomnography device, and radiography of pharyngeal tonsil were performed in 152 primary school children. RESULTS: The obstructive apnea hypopnea index (O-AHI) increased with enlargements in the palatine tonsils. The adenoidal nasopharyngeal ratio (A/N ratio) decreased with advances in grade. A significant difference was observed in the O-AHI between those with and without adenoid. The median value of the O-AHI increased with advances in grade. The nasal resistance was significantly higher in the group with adenoid compared as in the group without. It was also higher in the nasal disease group with OSA than in the group without. Full polysomnography(PSG) was recommended in 16 (10.5%) of 152 who underwent the examination using the portable polysomnography device, and of the eight who underwent PSG, six (75%) were confirmed to have OSA, while its prevalence in all subjects was estimated as 7.9%. CONCLUSIONS: Disturbances in nasal respiration as well as tonsillar hypertrophy and adenoid were found to be a risk factor of OSA in primary school children.

Assessment of cognitive function and sleep-wake rhythms in community-dwelling older adults.

Disruption of the circadian rhythm and sleep-wake cycles is a consequence of aging and is associated with the cognitive decline and many neurodegenerative conditions. We investigated the bedtime, wake-up time, sleep timing (midpoint between bedtime and wake-up time), and sleep timing standard deviation (SD) using the actigraphy among 80 consecutive volunteers aged ≥ 60 years. Global cognitive function and executive function of detailed cognitive domains were evaluated using the mini-mental state examination (MMSE) and Wisconsin card sorting test (WCST) and subjective daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). The category achievement (CA), total errors (TE), perseverative errors of Nelson (PEN), non-perseverative errors (NPE), and difficulties in maintaining set (DMS) on the WCST were significantly correlated with sleep timing SD (CA: r = - 0.276, p = 0.013, TE: r = 0.311, p = 0.005, PEN: r = 0.241, p = 0.032, NPE: r = 0.250, p = 0.025, DMS: r = 0.235, p = 0.036), but not with the MMSE score. Multiple regression analyses with the stepwise forward selection method including age, ESS score, bedtime, sleep timing, and sleep timing SD, revealed that the ESS score, and sleep timing SD were significant factors related to CA on the WCST (ESS score: ß = - 0.322, p = 0.004; sleep timing SD: ß = - 0.250, p = 0.022). Assessment of sleep-wake rhythms, daytime sleepiness, and cognitive function using the MMSE and WCST is valuable for the prediction of cognitive decline in the geriatric population.

Pilot study on the effects of a 1-day sleep education program: influence on sleep of stopping alcohol intake at bedtime.

The aim of this pilot study was to evaluate whether sleep was improved by a 1-day sleep education program in an occupational setting and whether stopping alcohol intake at bedtime might influence sleep. Subjects were 40 high school employees. The sleep education program lasted 4.5 hours and consisted of sleep science information, and sleep hygiene education including the risk of sleep related breathing disorder resulting from alcohol intake. Sleep conditions were evaluated by self-administered questionnaires at baseline and approximately 1 month later. The mean the Epworth Sleepiness Scale (ESS) score was significantly decreased by 1.2 points (P = 0.04), while the mean sleep duration was significantly decreased by 10 minutes (P = 0.02). Shortened sleep duration coincided with a decrease in sleepiness. This may indicate an improvement in sleep quality. The percentage of habitual alcohol intake at bedtime was significantly decreased (from 38.5% (15/39) to 20.5% (8/39), P = 0.04). Subjects who stopped alcohol intake at bedtime (n = 8) received the most benefit, with decreased scores of ESS and Insomnia Severity Index (ISI), although the reductions were not significant. This education program offers the possibility of improving sleep conditions among the general population, especially in those who cease habitual alcohol intake at bedtime. Further larger, randomized, controlled studies are warranted.

Insomnia and obstructive sleep apnea as potential triggers of dementia: is personalized prediction and prevention of the pathological cascade applicable?

INTRODUCTION: Sleep disorders ultimately result in sleep deficiency and poor-quality adversely impacts the immune system, glucose metabolism, body weight control, cardiovascular and cerebrovascular function, cognitive function, psychological stability, work productivity, quality of life, and social safety. Sleep disorders are very common among the elderly and are often comorbid with other diseases such as dementia, and further accelerating the underlying neurodegenerative processes. Initial studies have not clearly revealed the relationship between sleep disorders and dementia. Nonetheless, recent findings have suggested that insomnia and obstructive sleep apnea (OSA) are closely associated with dementia and perhaps they could be good predictors of occurrence of dementia and optimal treatments for sleep deficiencies may prevent or delay the onset dementia. METHODS: Here, we conducted a systematic review based on the criteria of predictive, preventive, and personalized medicine on the association of dementia in elderlies with sleep disorder, namely insomnia and OSA. We included 7432 studies and analyzed a total of 14 publications after applying appropriate exclusion criteria. RESULTS: We found that OSA patients had a large tendency to develop and/or experience accelerations of both Alzheimer's disease (AD) and also vascular dementia, whereas insomnia patients only develop and/or experience accelerations of AD. This may be reflected in the fact that AD and vascular dementia have similar and at the same time also different mechanisms of action. Several studies have also revealed that treating sleep disorders in elderly patients prevented or delayed the onset of dementia, mitigating the progression of symptoms in patients who already manifested dementic symptoms and even reversing neurodegeneration in particular brain areas. DISCUSSION: Currently, the general medical consensus has poorly addressed the role of sleep disorders in exacerbating the risk of dementia. Critically, studies such as the present one emphasizes that the treatment of sleep disorders could be one the preventive measures to evade or to improve dementia symptoms. Additionally, elderly individuals often manifest different sleep deficiency symptoms than younger ones. Given this, an improved age-specific categorization and evaluation methods for sleep deficiency need to be implemented in diagnosing dementia in order to enable personalized assessments and treatments. Collectively, these findings may also assist to improve efforts in predictively detecting and eventually treating dementia.

How much influence does inspiration have on pulse transit time in sleep apnea?

OBJECTIVES: To study how much affect inspiration has on pulse transit time (PTT). STUDY DESIGN: Prospective study. SUBJECTS AND METHODS: Polysomnograms were performed in 51 consecutive patients (male 45, female 6; ages 49.2 +/- 14.7 years) with obstructive sleep apnea. PTT changes during normal breathing, obstructive apnea (OA), and central apnea (CA) were compared, and the correlations between simultaneous changes in PTT and intraesophageal pressure (Peso) were discussed. RESULTS: In comparison with normal breathing, increases in PTT were greater in OA but significantly less in CA. The mean continuous increases in PTT were significantly higher in OA (17.0 +/- 4.9 ms) than those in CA (9.5 +/- 2.7 ms). Simultaneous changes in Peso and PTT correlated significantly but with a lower correlation coefficient in a portion of patients. CONCLUSIONS: Inspiration obviously affects PTT, and the linear relationship between simultaneous changes in PTT and Peso might be reflected to some extent.

A preliminary study on the influence of obstructive sleep apnea upon cumulative parasympathetic system activity.

OBJECTIVE: Although the autonomic nervous system plays a key role in mediating cardiovascular changes during obstructive sleep apnea (OSA), parasympathetic nervous system (PNS) activity during sleep apnea has not yet been sufficiently investigated. This study is to discuss the relationship between PNS activity and OSA. METHODS: Polysomnography recording was carried out in 76 patients (71 male and 5 female) with OSA. Cumulative PNS activity during sleep for each patient was derived from time series data of electrocardiogram (ECG) and analyzed by coarse graining spectral analysis of heart rate variability. The correlation between cumulative PNS activity and apnea-hypopnea index (AHI) was then discussed. RESULTS: Cumulative PNS activity and PNS peaks during sleep were lowly but significantly correlated with OSA severity (r=-0.344, p<0.005; and r=-0.266, p<0.05 respectively), and a linear regression equation could be established. Furthermore, significant correlation was also observed in the adult groups and in the moderate and severe groups, but not in the juvenile and the elderly and mild groups. CONCLUSION: These findings indicated that PNS function was obviously influenced by OSA during sleep. Cumulative PNS activity level might also serve as a useful parameter for the evaluation of OSA.

Self-reported Sleep Duration and Subclinical Atherosclerosis in a General Population of Japanese Men.

AIM: There are few data regarding associations between sleep duration and subclinical atherosclerosis in Japan. The aim of this study was to evaluate associations of self-reported sleep duration with calcification in the coronary arteries (CAC) and carotid intima media thickness (IMT) in Japanese men. METHODS: This was a cross-sectional survey of 1093 randomly selected men from Kusatsu City, Japan. Average sleep duration on weekdays was estimated through questionnaire; CAC by computed tomography; and carotid IMT by ultrasonography. RESULTS: The prevalence of CAC was 50.0% for participants with sleep duration ＜5.5 h, 43.9% with 5.5-6.4 h, 50.0% with 6.5-7.4 h, 49.3% with 7.5-8.4 h, and 62.5% with ≥8.5 h. In univariate analysis, participants with sleep duration ≥8.5 h had significantly higher prevalence of CAC than those with 6.5-7.4 h (p=0.043). After adjustment for age and other risk factors, however, the association was not significant (p=0.776). The average IMT was 0.85 mm for participants with sleep duration ＜5.5 h, 0.83 mm with 5.5-6.4 h, 0.85 mm with 6.5-7.4 h, 0.88 mm with 7.5-8.4 h, and 0.90 mm with ≥8.5 h. None of the differences in IMT observed in crude or multivariable-adjusted analyses was significant (all p＞0.1). CONCLUSION: Self-reported sleep duration was not associated with increased CAC or carotid IMT in a general population of Japanese men.

Pulse-oximetery is useful in determining the indications for adeno-tonsillectomy in pediatric sleep-disordered breathing.

OBJECTIVE: Although first line therapy of sleep-disordered breathing (SDB) in children is adeno-tonsillectomy, the indications for this operation have not yet been clearly established. We investigated whether pulse-oximetry is useful for determining the optional treatment modality for pediatric SDB. METHOD: Two hundred and thirty-two children presenting with snoring and gasping had their oxygen saturation levels examined during sleep. Among them, 86 underwent on adeno-tonsillectomy and were evaluated pre- and post-surgery. We also examined 25 healthy children as controls. RESULTS: Little desaturation was observed in healthy children. The difference in oxygen saturation levels of the patients between pre- and post-surgery was closely correlated with the pre-surgery levels. We examined the reaction operation characteristics and concluded that children with an oxygen desaturation index of 4% or more (ODI4) of more than 1.5 and/or ODI3 of more than 3.5 should undergo surgery. CONCLUSION: Pulse-oximetry is useful in determining the indications for adeno-tonsillectomy.

Evaluation of type 3 portable monitoring in unattended home setting for suspected sleep apnea: factors that may affect its accuracy.

OBJECTIVE: This study evaluates the reliability of type 3 portable monitoring (PM) in a home setting. STUDY DESIGN AND SETTING: Prospective study in sleep laboratory. Type 3 device (Stardust II) was evaluated in comparison with standard polysomnography (PSG) among patients with obstructive sleep apnea. Quality of recorded data and agreement between PM and PSG results were evaluated. RESULTS: Low quality of recorded data was observed only in 5 cases. Pattern of disordered breathing was recognized correctly by PM. Apnea/hypopnea index (AHI) correlated well with a mean bias of 3.7 +/- 13.1/h. High sensitivity of PM was observed generally, whereas specificity was lower in mild patients. AHI, record time, and sleep position were found to be the main factors that would affect the accuracy of PM. CONCLUSION: Type 3 PM is feasible in unattended home-setting for routine examination. Influence of the factors above should be comprehensively considered especially for mild patients.

Obstructive sleep apnea in preschool-aged Japanese children - efficiency of screening using lateral neck radiography.

Conclusions The prevalence of obstructive sleep apnea (OSA) in preschool-aged children diagnosed by the International Classification of Sleep Disorders (ICSD) version 3 criteria was relatively higher than that diagnosed by ICSD-2. Although the assessment of the upper airway by lateral neck radiography was effective for detecting OSA in this age group, this assessment is not recommended for all children as a screening method because of parental concern related to radiation exposure. Objective This study investigated the prevalence of OSA and the screening capacity of lateral neck radiography in community-based preschool-aged children. Methods Parents of 211 children aged 3-6 years were requested to complete the sleep-related questionnaire. Subjects who agreed to further investigations were invited to undergo home type 3 portable monitoring and clinical examination, including radiography. We estimated the prevalence of OSA and evaluated the detection power of radiography for predicting OSA. Results One hundred and eighty-eight (89.1%) subjects completed the questionnaire and 67 (31.8%) agreed to further examinations. The weighted prevalence was 7.3% and 12.8% by ICSD-2 and 3, respectively. Area under the receiver operator curve for the adenoidal/nasopharyngeal and tonsil/pharyngeal ratios measured using radiography was slightly larger than that for tonsil size graded by visual inspection.

A preliminary study on application of portable monitoring for diagnosis of obstructive sleep apnea.

Portable monitoring (PM) for diagnosis of obstructive sleep apnea has developed recently. Many studies were performed in the laboratory setting, with simultaneous polysomnographic recordings or required technical assistance in the home setting. And the data were automatically analyzed. In this study, we attempted to evaluate whether PM could be useful in fully unattended home setting, and whether the auto analysis of the data is reliable. Home setting examination by Stardust II, a novel PM device, was performed unattendedly on consecutive 62 patients who complained of snoring. The questionnaire survey on the difficulty of fitting and operation, and the discomfort was conducted by visual analog scale. Automatically and manually analyzed results were compared. The examination was successfully performed by all subjects. The difficulty of fitting and operation, and the discomfort were 2.9+/-1.9, 1.8+/-1.2 and 3.6+/-2.1, respectively. Auto analysis differed significantly from manual analysis not only in apnea/hypopnea index (AHI), but also in the construction of sleep disordered respiratory events. Although AHI in automatic and manual analysis had a good correlation (r=0.949; P<0.001), their agreement was poor, especially in mild and moderate cases. However, setting AHI=50 as a cut-off point in auto analysis, sensitivity and specificity could reach 100% and 92.5%, respectively. Accordingly, PM is useful to identify obstructive sleep apnea in an unattended home setting condition. Considering the significant difference between automatic and manual analysis, we suggest that the data analysis should be performed manually.

Maxillary cancer in a child: a case report.

Cases with maxillary cancer are most frequently found in the 5th to the 7th decades of life, and then rarely occur in adolescence, even less so in a children. One does not expect to encounter this tumor in children, considering that most have a non-epithelial origin. However, we had a case of maxillary squamous cell carcinoma which appeared in a 12-year-old boy. He was initially considered to have sinusitis, and received conservative treatment for a while. After diagnosis, a combination therapy consisting of preoperative irradiation along intra-arterial administration of 5-FU and CBDCA was followed by total maxillectomy and primary reconstruction. Unfortunately about 2 months later, distant metastasis developed along with local recurrence, and the boy died about 1 year 6 months after the initial presentation. The clinical details of this rare case will be discussed in conjunction with some important considerations in dealing with this type of malignancy in a child.

Type I Chiari malformation presenting central sleep apnea.

Sleep apnea is a rare but a well-known clinical feature of type I Chiari malformation. It may be obstructive or central in nature. Sleep apnea in patients with type I Chiari malformation rarely presents without accompanying neurological signs or symptoms. We here report a case of a 10-year-old girl who presented with central sleep apnea without any other neurological signs but was ultimately diagnosed with type I Chiari malformation. The patient initially showed mild improvement in symptoms after administration of an acetazolamide. Finally, posterior fossa decompression dramatically improved her respiratory status during sleep, both clinically and on polysomnography. This case suggests that type I Chiari malformation should be considered in the differential diagnoses of central apneas in children, even if there are no other neurological signs and symptoms. Furthermore, sagittal craniocervical magnetic resonance imaging may be necessary for a definitive diagnosis.

Evaluation of adenotonsillectomy and tonsillectomy for pediatric obstructive sleep apnea by rhinomanometry and the OSA-18 questionnaire.

CONCLUSION: Nasal resistance and the OSA-18 score were useful for evaluating surgical treatments. The sleep disturbance score may also be useful for predicting the severity of obstructive sleep apnea (OSA) in children. OBJECTIVE: We evaluated the effect of surgery on children with OSA using polysomnography (PSG) parameters, nasal resistance, and the OSA-18 questionnaire, and also investigated the cut-off OSA-18 score to screen for pediatric OSA. METHODS: This was a retrospective study in which PSG parameters and nasal resistance were measured using a rhinomanometer and the OSA-18 score was obtained from the OSA-18 questionnaire before and after surgery in 45 children with OSA. RESULTS: The mean age of the 45 patients was 5.7 ± 2.0 years. The mean value of the obstructive apnea hypopnea index (O-AHI) improved from 16.2 ± 14.3/h before surgery to 1.1 ± 1.7/h after surgery, the mean nasal resistance improved from 0.44 ± 0.19 to 0.32 ± 0.10 Pa/cm(3)/s, and the mean OSA-18 score improved from 61.1 ± 13.7 to 30.4 ± 5.8, and all these improvements were significant. The O-AHI value was lower than 1/h after surgery in 64.4% of patients (29/45). The O-AHI value was significantly correlated with the sleep disturbance score (r = 0.352, p = 0.018). When the cut-off OSA-18 score for screening was set at 40, sensitivity was 100%.