Sleep Disturbances in MCI and AD: Neuroinflammation as a Possible Mediating Pathway.

Mild cognitive impairment (MCI) and Alzheimer's disease (AD) affect a high proportion of the elderly population with an increasing prevalence. Sleep disturbances are frequent in those with MCI and AD. This review summarizes existing research on sleep disturbances and neuroinflammation in MCI and AD. Although strong evidence supports various pathways linking sleep and AD pathology, the temporal direction of this central relationship is not yet known. Improved understanding of sleep disturbance and neuroinflammation in MCI and AD may aid in the identification of targets for their prevention.

Observation and Interview-based Diurnal Sleepiness Inventory for measurement of sleepiness in patients referred for narcolepsy or idiopathic hypersomnia.

STUDY OBJECTIVES: First, to determine whether the 3-item Observation and Interview-based Diurnal Sleepiness Inventory (ODSI) measures the degree of excessive daytime sleepiness in patients with suspected narcolepsy or idiopathic hypersomnia (IH). Second, to assess the correlation between the ODSI and the Epworth Sleepiness Scale (ESS) as well as objective polysomnographic measurements. Third, to test the accuracy of the ODSI to detect narcolepsy or IH (narcolepsy/IH) compared with the ESS. METHODS: A total of 181 patients complaining of excessive daytime sleepiness filled in the ESS and the ODSI and underwent measurements including actigraphy, full-night polysomnography, Multiple Sleep Latency Test, and 24-hour bedrest sleep recording. RESULTS: Narcolepsy or IH was diagnosed in 76 patients. The ODSI found excessive daytime sleepiness in 92.3% of all patients and in 98.7% of those diagnosed with narcolepsy/IH. In the whole population, the ODSI was significantly positively correlated with the ESS (R = .547; 95% confidence interval: .436, .642; P < .001) and weakly with 24-hour total sleep time on bedrest recording (R = .208; 95% confidence interval: .056, .350; P = .047) but not with the Multiple Sleep Latency Test. The ODSI offered a higher negative (92.9%) and positive (44.9%) predictive value to detect narcolepsy/IH than did the ESS (66.7% and 43.3%, respectively). In the IH group, the ODSI's third-item score (daily sleepiness duration) was significantly higher in patients with than without increased 24-hour total sleep time (P = .023). CONCLUSIONS: The ODSI is a brief, simple first-line questionnaire that explores both intensity and duration of daytime sleepiness and offers a high sensitivity to detect narcolepsy and IH.

Observation and Interview-based Diurnal Sleepiness Inventory for measurement of sleepiness in older adults.

INTRODUCTION: There is no established reference standard for subjective measures of sleepiness in older adults. METHODS: This study compares the Observation and Interview-based Diurnal Sleepiness Inventory (ODSI) with two existing instruments for measurement of sleepiness and daily functioning, the Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ). RESULTS: A total of 125 study participants were included in this study and were administered the ODSI, ESS and FOSQ; subjects had a mean age of 70.9 ± 5.27 years, mean Apnea-Hypopnea Index of 31.9 ± 27.9 events/hour and normal cognitive functioning (Mini-Mental State Examination score > 24). The ODSI showed a significant association with the ESS (Spearman's ρ: 0.67, P < 0.001) and with the FOSQ (Spearman's ρ: -0.52, P < 0.001). The ODSI 1 item (assessing sleepiness in active situations) was borderline significantly correlated with the ESS (ß = 0.14; 95% confidence interval [CI], -0.01 to 0.29; P = 0.069). ODSI 2 item (sleepiness in passive situations) was correlated with the ESS (ß = 1.65; 95% CI, 1.32 to 1.98; P < 0.001). Both ODSI 1 (ß = -0.15; 95% CI, -0.24 to -0.07; P < 0.001) and ODSI 2 (ß = -0.35; 95% CI, -0.55 to 0.16; P < 0.001) were significantly correlated with the FOSQ. CONCLUSION: The ODSI is a suitable measure of sleepiness and is appropriate for usage in clinical care in older adults.

Limits of the Epworth Sleepiness Scale in older adults.

PURPOSE: Excessive daytime sleepiness (EDS) in older adults is associated with obstructive sleep apnea, falls, reduced quality of life, and mortality. The Epworth Sleepiness Scale (ESS) is widely used to assess sleepiness. However, EDS assessment with the ESS may not be accurate in older adults. We aimed to (1) describe the responsiveness of nondemented older subjects to the ESS and (2) compare the self-report ESS scores to those of close relatives (CR) proxy and identify factors influencing any discrepancies between them. METHODS: This is a cross-sectional observational study including 104 independently living nondemented older subjects with daytime sleepiness complaints and 104 nondemented CRs. Cognitive tests (Mini-Mental State Examination) and the ESS were completed separately by subjects and CRs to assess the subject's daytime sleepiness. RESULTS: Almost 60 % of subjects and CRs were not able to answer at least one question on the ESS. Despite the fact that all subjects complained of EDS, only 24 % of them had an abnormal ESS score (>10). Subjects rated their sleepiness lower (7.10 ± 4.31) than their CR proxy did (9.70 ± 5.14) (p < 0.0001). In multivariate analysis, an increase in age and a decrease in cognitive status of the subjects appeared related to the difference in ESS between subject and CR. CONCLUSIONS: The majority of older adults were not able to answer all of the ESS items. The ESS may underestimate sleepiness severity in older subjects. Despite EDS complaints in all subjects, only one quarter of them had a pathological ESS score.

Occult nighttime hypertension in daytime normotensive older patients with obstructive sleep apnea.

OBJECTIVES: To assess nighttime blood pressure (BP), the dipping phenomenon and the relationships between nighttime BP, and polysomnography parameters in older patients with obstructive sleep apnea (OSA) who have been identified by their primary care physician as being normotensive during the daytime. DESIGN: Cross-sectional study. SETTING: University hospital-based geriatric sleep center. PARTICIPANTS: Daytime normotensive, community-dwelling older adults, consecutively referred by their primary care physicians for suspicion of OSA. MEASUREMENTS: Overnight polysomnography and 24-hour ambulatory blood pressure measurement (ABPM). Daytime hypertension defined as systolic BP ≥135 mm Hg and/or diastolic BP ≥85 mm Hg. Nighttime hypertension defined as systolic BP ≥120 mm Hg and/or diastolic BP ≥70 mm Hg. Dipper pattern characterized by nighttime fall of mean BP ≥10%. RESULTS: Forty-five participants (30 OSA; 15 non-OSA) completed the study (76.9 ± 6.2 years old). ABPM indicated clinically significant nighttime systolic (132.5 ± 16.0) and diastolic (72.6 ± 9.4) hypertension in patients with OSA previously classified as daytime normotensives and found only a mild degree of nighttime systolic hypertension (123.7 ± 16.1) in patients without OSA (P = .105). A significant nondipping phenomenon was found in patients with OSA (-0.5 ± 7.4 vs 5.4 ± 6.4; P = .016). Nighttime mean BP (r = 0.301; P = .049) and dipping status (r = -0.478; P = .001) were correlated with apnea-hypopnea index. A significant correlation was found between systolic BP (r = 0.321; P = .035), diastolic BP (r = 0.373; P = .013), mean BP (r = 0.359; P = .018), and hypoxia (sleep time spend with SaO2 <90%). CONCLUSION: Daytime normotensive older adults with OSA are at high risk for having occult nighttime hypertension. Thus, 24-hour ABPM may be appropriate for older patients with OSA whose clinical blood pressure does not display any daytime elevation.

Pain tolerance and obstructive sleep apnea in the elderly.

OBJECTIVE: Patients with painful conditions often suffer from sleep disturbances. However, changes in sleep pattern per se could also influence pain tolerance. Untreated obstructive sleep apnea (OSA) causes major disturbances in sleep pattern. The aim of this study was to assess whether continuous positive airway pressure (CPAP) treatment in elderly patients with OSA would result in improved pain tolerance. DESIGN: Randomized, double-blind crossover study. SETTING: Geriatric sleep center based in Antoine Charial University Hospital (Lyon, France). PARTICIPANTS: A total of 13 consecutive OSA patients aged 70 and older randomly assigned CPAP treatment (lowCPAP versus highCPAP). Eleven patients completed the study. MEASUREMENTS: Overnight sleep recording, electrical pain tolerance assessment, and visual analog scale for sleep quality were performed. RESULTS: Both low- and highCPAP treatment significantly improved respiratory parameters. However, compared with baseline, the electrical pain tolerance score was significantly enhanced (analgesic effect) only under highCPAP treatment (21.2 ± 10.9 versus 28.4 ± 16.0; P = .03). CONCLUSION: The treatment of OSA with CPAP would have an analgesic effect. This would represent a unique outcome attributed to CPAP treatment. Given the high prevalence of both OSA and chronic pain conditions in the elderly; our findings could hold many implications for very large segments of the elderly population.

Falling-asleep-related injured falls in the elderly.

OBJECTIVES: To describe the clinical features and therapeutic response to continuous positive airway pressure (CPAP) in elderly obstructive sleep apnea syndrome (OSAS) patients with sleepiness and falling-asleep-related injured falls. PATIENTS AND METHODS: In 2 geriatric units, 4 consecutive OSAS patients with falling-asleep-related injured falls were diagnosed. They were treated with CPAP and followed for 9 to 24 months. RESULTS: Mean age at initial observation was 82 years. All patients shared the following characteristics: self-reported daytime sleepiness, falling-asleep-related injured falls, recurrent fall history, medical comorbid conditions, PSG confirmed OSAS, and successful treatment with CPAP. They declared resolution of sleepiness and attention without any further fall under CPAP therapy. CONCLUSION: A causal relationship exists between OSAS and falling-asleep-related injured falls in the elderly. Treatment of OSAS with CPAP can improve attention, daytime vigilance, and consequently gait and balance control and prevent falls in these patients.

Observation-based nocturnal sleep inventory: screening tool for sleep apnea in elderly people.

OBJECTIVES: To measure the ability of the Observation-based Nocturnal Sleep Inventory (ONSI) to detect the presence or absence of sleep apnea syndrome (SAS) in older adults. DESIGN: Cross-sectional blinded study. SETTING: University hospital-based geriatric sleep center. PARTICIPANTS: All participants aged 70 and older were referred by physicians for suspicion of SAS. MEASUREMENTS: ONSI performed by nurses; overnight polysomnography. SAS was defined as an apnea-hypopnea index of 15 events or more per hour of sleep. RESULTS: A total of 121 consecutive patients were evaluated for study participation. Six were excluded because of technical difficulties with polysomnography or too-frequent awakenings related to medical conditions. One hundred eleven patients completed the validation process. Polysomnography identified 68 patients as having SAS and 43 patients as not having SAS. The nurse-administered ONSI demonstrated good levels of sensitivity (90%), specificity (81%), positive predictive value (88%), and negative predictive value (83%) in screening older adults for SAS. CONCLUSION: The ONSI is the first valid SAS screening tool proposed for older persons in hospitals and nursing homes. This study demonstrates that the ONSI provides accurate information; is a simple, easy-to-use bed-side tool; and is highly sensitive and specific in screening SAS when compared with overnight polysomnography results.

Alcohol abuse and dependence in elderly emergency department patients.

Although elderly people are particularly vulnerable to the adverse effects of alcohol, alcohol use disorders in late life have received relatively little attention in the literature. Our objectives were to assess the prevalence of alcohol use disorders (abuse and dependence), the medical profile and psychosocial characteristics in elderly people visiting emergency department (ED). A cohort of 2405 patients aged over 60 who came to the ED of a university hospital during a 3-month period was studied. Alcohol use disorder diagnosis (DSM-IV), medical profile and social characteristics were collected from retrospective review of patient files. The data derived from 128 patients (mean age, 69.8+/-6.8 years; 87% males) with alcohol use disorders and 128 non-alcoholic controls. The prevalence of current alcohol use disorder was 5.3%. The most common current alcohol-induced disorders were alcohol intoxication and alcohol-induced mood disorder. Social factors associated with alcohol use disorders were being homeless, living alone, being divorced and never married. Falls and delirium were frequent ED admission circumstances in elderly drinkers. Drinkers more commonly presented with gastrointestinal disorders. In conclusion, alcohol use disorders among older patients admitted in ED are common and occur more frequently among men. Falls and delirium are the main ED admission circumstances in elderly drinkers. Alcohol use disorders are also associated with gastrointestinal problems.

How pain and analgesics disturb sleep.

OBJECTIVE: Clinical experiences as well as specific investigations show that pain and sleep disturbances are closely correlated. The aims of this review are first to describe sleep disturbances related to painful medical diseases and analgesics and secondly to propose management possibilities for these sleep disturbances. METHOD: The viewpoints presented were based mainly on objective rest activity and sleep studies using actigraphy and polysomnography. RESULTS: Polysomnographic and actigraphic studies have described significant sleep disturbances in patients suffering from different pain disorders. These disturbances are: reduced sleep efficiency and altered sleep architecture characterized by increased wakefulness and stage 1 non-rapid eye movement sleep, associated with diminished slow wave sleep and rapid eye movement sleep. Sleep disturbances may be related to pain and to the analgesic or sedative medications administered. CONCLUSION: If many factors, including pain, disease process per se, as well as medication, could disturb sleep, sleep disturbances may also adversely affect the natural course of the painful disease. Improving sleep quantity and quality in patients with painful disorders may break this vicious circle and as consequence enhance the patients' overall health and quality of life.