Sleep in disorders of consciousness: behavioral and polysomnographic recording.

BACKGROUND: Sleep-wakefulness cycles are an essential diagnostic criterion for disorders of consciousness (DOC), differentiating prolonged DOC from coma. Specific sleep features, like the presence of sleep spindles, are an important marker for the prognosis of recovery from DOC. Based on increasing evidence for a link between sleep and neuronal plasticity, understanding sleep in DOC might facilitate the development of novel methods for rehabilitation. Yet, well-controlled studies of sleep in DOC are lacking. Here, we aimed to quantify, on a reliable evaluation basis, the distribution of behavioral and neurophysiological sleep patterns in DOC over a 24-h period while controlling for environmental factors (by recruiting a group of conscious tetraplegic patients who resided in the same hospital). METHODS: We evaluated the distribution of sleep and wakefulness by means of polysomnography (EEG, EOG, EMG) and video recordings in 32 DOC patients (16 unresponsive wakefulness syndrome [UWS], 16 minimally conscious state [MCS]), and 10 clinical control patients with severe tetraplegia. Three independent raters scored the patients' polysomnographic recordings. RESULTS: All but one patient (UWS) showed behavioral and electrophysiological signs of sleep. Control and MCS patients spent significantly more time in sleep during the night than during daytime, a pattern that was not evident in UWS. DOC patients (particularly UWS) exhibited less REM sleep than control patients. Forty-four percent of UWS patients and 12% of MCS patients did not have any REM sleep, while all control patients (100%) showed signs of all sleep stages and sleep spindles. Furthermore, no sleep spindles were found in 62% of UWS patients and 21% of MCS patients. In the remaining DOC patients who had spindles, their number and amplitude were significantly lower than in controls. CONCLUSIONS: The distribution of sleep signs in DOC over 24 h differs significantly from the normal sleep-wakefulness pattern. These abnormalities of sleep in DOC are independent of external factors such as severe immobility and hospital environment.

Time-of-day effects on prospective memory.

Cognitive performance fluctuates during the course of a day. Different cognitive functions show optimal performance at different times of the day, known as the 'time-of-day effect'. While this effect has been observed for a number of cognitive domains including declarative memory, it is presently unclear whether performance fluctuations are also seen in prospective memory, i.e. memory for intentions to be realized in the future. The present study examined time-of-day effects in four different prospective memory tasks with varying degrees of complexity, taking into account circadian preference (i.e. morningness-eveningness/chronotype) and attentional resources (in one of the tasks). In a pilot study (n = 48) and a main experiment (n = 39), prospective memory was compared between morning groups (˜09:00) and evening groups (˜21:00) of young adults. We found time-of-day effects, with better performance in the evening than in the morning, in a simple one-item prospective memory task (Red Pencil Task, p = .02), a classical event-based prospective memory task including the detection of cue syllables in a lexical decision ongoing task (Syllable Detection Task, p < .048), and a rather naturalistic complex planning task for breakfast preparation (Dresden Breakfast Task, including time-based prospective memory (p = .026) and event-based prospective memory (p = .054)). These time-of-day effects were neither modulated by circadian preference nor by attentional resources. Another simple one-item prospective memory task was not affected by time of day (Color Task, p = .14). Ongoing task performance in the Syllable Detection Task and the Dresden Breakfast Task, overall, did not differ significantly between morning and evening groups. These findings provide tentative evidence for time-of-day effects in prospective memory of young adults, with better performance in the evening hours.

Effects of sleep on the realization of complex plans.

Sleep consolidates newly encoded memories, particularly those memories that are relevant for future behaviour. This study explored whether sleep facilitates the successful execution of relatively complex plans in the future. We applied the Dresden Breakfast Task, in which subjects are instructed to prepare a virtual breakfast comprising several tasks (e.g. table-setting, preparing eggs). After forming a detailed plan how to realize these tasks, the sleep group (n = 17) spent a night of sleep at home, monitored by polysomnography, and the wake group (n = 19) spent a normal day awake, monitored by actigraphy. After a 12-h interval, all participants were asked to prepare the virtual breakfast. Contrary to our hypothesis, overall performance in breakfast preparation did not differ significantly between the sleep and wake groups. However, sleep participants performed better in one of six tasks, specifically the 'table-setting' task (P < 0.01), which was driven by higher scores in a subtask measuring the correct position of the tableware (P < 0.01). Additional exploratory analyses revealed that a significant number of wake participants performed below the minimal score of the sleep group (P < 0.01) and sleep participants achieved the maximal score in significantly more subtasks than wake participants (57% versus 27%; P = 0.018). Plan adherence, assessing how well participants adhered to their own previously developed plan, did not differ between the sleep and wake groups. These findings provide the first evidence that sleep may support some aspects of the realization of complex, somewhat naturalistic plans.

Consolidation of Prospective Memory: Effects of Sleep on Completed and Reinstated Intentions.

Sleep has been shown to facilitate the consolidation of prospective memory, which is the ability to execute intended actions at the appropriate time in the future. In a previous study, the sleep benefit for prospective memory was mainly expressed as a preservation of prospective memory performance under divided attention as compared to full attention. Based on evidence that intentions are only remembered as long as they have not been executed yet (cf. 'Zeigarnik effect'), here we asked whether the enhancement of prospective memory by sleep vanishes if the intention is completed before sleep and whether completed intentions can be reinstated to benefit from sleep again. In Experiment 1, subjects learned cue-associate word pairs in the evening and were prospectively instructed to detect the cue words and to type in the associates in a lexical decision task (serving as ongoing task) 2 h later before a night of sleep or wakefulness. At a second surprise test 2 days later, sleep and wake subjects did not differ in prospective memory performance. Specifically, both sleep and wake groups detected fewer cue words under divided compared to full attention, indicating that sleep does not facilitate the consolidation of completed intentions. Unexpectedly, in Experiment 2, reinstating the intention, by instructing subjects about the second test after completion of the first test, was not sufficient to restore the sleep benefit. However, in Experiment 3, where subjects were instructed about both test sessions immediately after learning, sleep facilitated prospective memory performance at the second test after 2 days, evidenced by comparable cue word detection under divided attention and full attention in sleep participants, whereas wake participants detected fewer cue words under divided relative to full attention. Together, these findings show that for prospective memory to benefit from sleep, (i) the intention has to be active across the sleep period, and (ii) the intention should be induced in temporal proximity to the initial learning session.