Poor sleep quality and silent markers of cerebral small vessel disease: a population-based study in community-dwelling older adults (The Atahualpa Project)

Functional and vascular neuroimaging in maritime pilots with long-term sleep disruption

The mechanism underlying the possible causal association between long-term sleep disruption and Alzheimer's disease remains unclear Musiek et al. 2015. A hypothesised pathway through increased brain amyloid load was not confirmed in previous work in our cohort of maritime pilots with long-term work-related sleep disruption Thomas et al. Alzheimer's Res Ther 2020;12:101. Here, using functional MRI, T2-FLAIR, and arterial spin labeling MRI scans, we explored alternative neuroimaging biomarkers related to both sleep disruption and AD: resting-state network co-activation and between-network connectivity of the default mode network (DMN), salience network (SAL) and frontoparietal network (FPN), vascular damage and cerebral blood flow (CBF). We acquired data of 16 maritime pilots (56 ± 2.3 years old) with work-related long-term sleep disruption (23 ± 4.8 working years) and 16 healthy controls (59 ± 3.3 years old), with normal sleep patterns (Pittsburgh Sleep Quality Index ≤ 5). Maritime pilots did not show altered co-activation in either the DMN, FPN, or SAL and no differences in between-network connectivity. We did not detect increased markers of vascular damage in maritime pilots, and additionally, maritime pilots did not show altered CBF-patterns compared to healthy controls. In summary, maritime pilots with long-term sleep disruption did not show neuroimaging markers indicative of preclinical AD compared to healthy controls. These findings do not resemble those of short-term sleep deprivation studies. This could be due to resiliency to sleep disruption or selection bias, as participants have already been exposed to and were able to deal with sleep disruption for multiple years, or to compensatory mechanisms Mentink et al. PLoS ONE. 2021;15(12):e0237622. This suggests the relationship between sleep disruption and AD is not as strong as previously implied in studies on short-term sleep deprivation, which would be beneficial for all shift workers suffering from work-related sleep disruptions.

Older cerebral small vessel disease and sleep disturbance: A diffusion tensor imaging study

OBJECTIVE

This study examined the relationship between diffusion tensor imaging indicators and brain network characteristics in patients with cerebral small vessel disease (CSVD) with (CSVD + S) and without (CSVD-S) sleep disturbance. We explored the feasibility of using these imaging biomarkers to investigate the pathophysiological mechanisms underlying sleep disturbance in patients with CSVD.

METHODS

A total of 146 patients with CSVD and 84 healthy controls were included. Sleep quality was assessed using polysomnography and the Pittsburgh Sleep Quality Index. Tract-based spatial statistics and graph theory were applied to compare white matter lesions and brain network characteristics, which were then used for backpropagation artificial neural network (BPANN) analysis.

RESULTS

Compared with the control group, the CSVD + S group showed a decrease in total sleep time and sleep efficiency, as well as higher values for sleep onset latency, wake after sleep onset, and non-rapid eye movement sleep stage 1. Both the CSVD + S and CSVD-S groups exhibited reduced fractional anisotropy and structural connectivity strength. However, the CSVD + S group showed increased mean diffusivity in affected fiber bundles (the anterior thalamic radiation, frontal occipital fasciculus, and superior longitudinal fasciculus) in key brain regions, such as the thalamus and frontal lobe, that regulate sleep and wakefulness. In addition, the CSVD + S group showed significant impairments in global, node, and small-world attributes. The BPANN model successfully predicted sleep disturbance in patients with CSVD.

CONCLUSION

Our findings support the possibility that white matter abnormalities in subcortical neural circuits and microstructural and functional changes in brain connections underly CSVD sleep disturbance.

Bathing-Related Ischemic Stroke: Association between Stroke Subtype and Cerebral Small Vessel Disease

AIMS

Bathing-related ischemic stroke (BIS) is sometimes fatal. However, its mechanisms and risk factors remain unclear. We aimed to identify the incidence of stroke subtypes in BIS, and clarify the impact of cerebral small vessel disease (CSVD) on BIS.

METHODS

Consecutive patients with ischemic stroke between October 2012 and February 2022 were retrospectively screened. The inclusion criteria were: 1) onset-to-door time within 7 days; and 2) availability of the results of MRI evaluation of CSVD markers during hospitalization. BIS was defined as an ischemic stroke that occurred while or shortly after bathing. We investigated the incidence of the stroke subtype and the correlation between CSVD markers and BIS.

RESULTS

1,753 ischemic stroke patients (1,241 [71%] male, median age 69 years) were included. 57 patients (3%) were included in the BIS group. A higher frequency of large artery atherosclerosis (LAA) (prevalence ratio [PR] 2.069, 95% confidence interval [CI] 1.089 to 3.931, p=0.026) and lower frequency of cardio-embolism (CES) (PR 0.362, 95% CI 0.132 to 0.991, p=0.048) in BIS cases were identified. Moreover, lower periventricular hyperintensity (PVH) Fazekas grade (PR 0.671, 95% CI 0.472 to 0.956, p=0.027) and fewer cerebral microbleeds (CMBs) in deep brain region (PR 0.810, 95%CI 0.657 to 0.999, p=0.049) were associated with BIS cases.

CONCLUSIONS

The BIS group was more likely to develop LAA and less likely to develop CES. Lower PVH grade and fewer CMBs in deep brain region were associated with the development of BIS.

Effects of sleep fragmentation on white matter pathology in a rat model of cerebral small vessel disease

STUDY OBJECTIVES

Mounting evidence indicated the correlation between sleep and cerebral small vessel disease (CSVD). However, little is known about the exact causality between poor sleep and white matter injury, a typical signature of CSVD, as well as the underlying mechanisms.

METHODS

Spontaneously hypertensive rats (SHR) and control Wistar Kyoto rats were subjected to sleep fragmentation (SF) for 16 weeks. The effects of chronic sleep disruption on the deep white matter and cognitive performance were observed.

RESULTS

SHR were validated as a rat model for CSVD. Fragmented sleep induced strain-dependent white matter abnormalities, characterized by reduced myelin integrity, impaired oligodendrocytes precursor cells (OPC) maturation and pro-inflammatory microglial polarization. Partially reversible phenotypes of OPC and microglia were observed in parallel following sleep recovery.

CONCLUSIONS

Long-term SF-induced pathological effects on the deep white matter in a rat model of CSVD. The pro-inflammatory microglial activation and the block of OPC maturation may be involved in the mechanisms linking sleep to white matter injury.

Deep and infratentorial cerebral microbleeds are related to wake-up stroke by large-artery atherosclerosis and cardioembolism

BACKGROUND AND AIMS

Circadian variability of blood pressure (BP) and hypercoagulation in the morning have been proposed as underlying mechanisms of wake-up stroke (WUS). The aim was to determine the impact of cerebral microbleeds (CMBs), showing BP fluctuation and background hypercoagulability, on WUS.

METHODS

Consecutive patients with acute ischemic stroke onset-to-door time within one week were screened. WUS was defined as an ischemic stroke that occurred during sleep at night. CMBs were categorized into three: "strictly Lobar", "strictly Deep (D) and/or Infratentorial (I)", and "Mixed". Moderate to severe CMBs were defined as having more than three in total. First, whether CMBs are associated with WUS was examined. Second, the same analysis was performed according to the stroke subtype classified as large-artery atherosclerosis (LAA), cardioembolism (CE), and small-vessel occlusion (SVO).

RESULTS

A total of 1477 patients (1059 [72%] male, median age 69 years) were included, and WUS was observed in 363 (25%) patients. On Poisson regression analysis with a robust variance estimator in the total cohort, moderate to severe strictly D and/or I CMBs (PR 1.505, 95% CI 1.154-1.962, p = 0.003) were associated with WUS. From the perspective of stroke subtype, the same result was confirmed in LAA (PR 2.223, 95% CI 1.036-4.768, p = 0.040) and CE (PR 1.668, 95% CI 1.027-2.709, p = 0.039), not SVO.

CONCLUSIONS

The presence of moderate to severe strictly D and/or I CMBs might be associated with the development of WUS. By stroke subtype, the same result was confirmed in LAA and CE.

The relationship between apathy and nonparametric variables of rest activity rhythm in older adults with cerebral small vessel disease

The goal of the current study was to demonstrate if the rest-activity rhythm (RAR) was altered in apathetic older adults with cerebral small vessel disease (CSVD) and find out the relationship between apathy/depression severity and RAR features in CSVD patients. This is a cross-sectional observational investigation including 53 CSVD cases (54.74% men), aged 70.70 ± 6.18 years old. The participants were assessed by neuropsychiatric inventory (NPI) subscale of apathy (NPI-apathy) and depression (NPI-depression) in succession, according to updated diagnostic criteria for apathy (DCA). Each subject wore an actigraph device (ActiGraph GT3X) in their nondominant hand for 7 days to collect raw data. Using a non-parametric methodological analysis, this study determined RAR variables such as interdaily stability (IS), intraday variability (IV) and relative amplitude (RA). Patients in the apathy-positive group had a higher Fazekas score than those in the apathy-negative group. IS, but not IV, RA, or objective sleep variables, differed between elderly patients with varying degrees of CSVD burden. Furthermore, apathy severity was statistically correlated with RA after adjusting for age, gender and education level, whereas depression severity was not associated with RAR variables. Finally, we discovered that the severity of apathy had no significant relationship with the severity of depression. All these findings indicated that the RAR altered in apathetic older adults with CSVD, and apathy was associated with decreased RAR amplitude.

The state of brain activity modulates cerebrospinal fluid transport

Earlier studies based on 2-photon imaging have shown that glymphatic cerebrospinal fluid (CSF) transport is regulated by the sleep-wake cycle. To examine this association, we used 3DISCO whole-body tissue clearing to map CSF tracer distribution in awake, sleeping and ketamine-xylazine anesthetized mice. The results of our analysis showed that CSF tracers entered the brain to a significantly larger extent in natural sleep or ketamine-xylazine anesthesia than in wakefulness. Furthermore, awake mice showed preferential transport of CSF tracers in the rostro-caudal direction towards the cervical and spinal cord lymphatic vessels, and hence to venous circulation and excretion by the kidneys. The study extends the current literature by showing that CSF dynamics on the whole-body scale is controlled by the state of brain activity.

Type A personality, sleep quality, and cerebral small vessel disease: investigating the mediating role of sleep in a community-based study

Purpose

Type A behavior pattern (TABP) is a personality type characterized by rapid speech, impatience, competition, and hostility. Asymptomatic cerebral small vessel disease (CSVD) is often endemic in older adults. Individuals with TABP commonly experience suboptimal sleep quality, and a correlation exists between sleep disturbances and CSVD. We investigated the relationship between TABP and CSVD markers and further explored the mediating role of sleep quality in the relationship between TABP and CSVD.

Methods

A cross-sectional survey included 764 community-dwelling adults aged 55-85 years. The TABP Scale and the Pittsburgh Sleep Quality Index (PSQI) were used to assess personality and sleep quality, respectively. Linear and logistic regression analyses were used to examine relationships between variables of interest. In addition, mediation analyses with bootstrapping were used to test whether sleep quality mediated the relationship between TABP and CSVD.

Results

Of the 764 participants [median age 65 (61-69) years, 59.9% female], the population with type A personality accounted for 44.8%. After adjusting for covariates, TABP scores (p = 0.03) and PSQI scores (p < 0.001) were significantly correlated with CSVD. In addition, sleep quality partially mediated the association between type A behavior and CSVD, and the mediating effect was 10.67%.

Conclusion

This study showed that type A behavior was a risk factor for CSVD among older community-dwelling adults and that sleep quality mediated the relationship between type A behavior and CSVD. Changing type A behavior may help improve sleep quality, which may in turn reduce the prevalence of CSVD.

Differences in Gray Matter Volume in Cerebral Small Vessel Disease Patients with and without Sleep Disturbance

Recently, there has been increased interest in the relationship between cerebral small vessel disease (CSVD) and circadian rhythm disruption, particularly sleep disturbance. However, the neural mechanism of sleep disturbance in CSVD patients remains poorly understood. The purpose of this study is to explore the gray matter alterations in CSVD patients with and without sleep disturbance. 59 patients with CSVD and 40 healthy controls (HC) were recruited for the present study. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. CSVD patients were categorized into either the good sleepers group (CSVD-GS, n = 23) or the poor sleepers group (CSVD-PS, n = 36) based on PSQI score. Voxel-based morphometry (VBM) analysis was used to assess differences in gray matter volume (GMV) between groups. Multivariate regression analyses were performed to investigate the relationships between sleep quality, GMV, and white matter hyperintensities (WMH). We observed GMV differences between the three groups in the bilateral caudate, right thalamus, bilateral calcarine cortex, left precentral gyrus, right orbitofrontal cortex, left cingulate gyrus, and right sub-gyral temporal lobe. Additionally, the CSVD-PS group exhibited decreased GMV in the bilateral calcarine cortex yet increased GMV in the right caudate compared to the CSVD-GS group. In fully adjusted models, GMV of the right caudate and bilateral calcarine cortex was associated with sleep quality in CSVD patients. The present study revealed structural brain alterations in CSVD patients with sleep disturbance. These findings may provide novel insights into the neural mechanisms of sleep disturbance in CSVD.

Obstructive sleep apnea is associated with markers of cerebral small vessel disease in a dose-response manner: A systematic review and meta-analysis

Cerebral small vessel disease manifests on neuroimaging as white matter hyperintensities, lacunes, cerebral microbleeds, perivascular spaces or subcortical infarcts and is a major contributor to dementia, stroke and incident death. We aimed to determine whether obstructive sleep apnea severity is associated cerebral small vessel disease. A systematic search was conducted for studies examining the association between obstructive sleep apnea and cerebral small vessel disease markers. A random-effects model was used to meta-analyze unadjusted odds ratios derived from event rates. The neuroimaging-derived measures of white matter hyperintensities, lacunes, and cerebral microbleeds were compared against increasing obstructive sleep apnea severity, as measured by apnea-hypopnea indices of <5, 5-15, ≥15 and ≥ 30. Thirty-two observational studies were included: ten reported effect sizes for white matter hyperintensities, nine for lacunes and three for cerebral microbleeds. Compared to patients without obstructive sleep apnea, the odds of possessing white matter hyperintensities were 1.7 [95% confidence interval 0.9-3.6] in mild, 3.9 [2.7-5.5] in moderate-severe and 4.3 [1.9-9.6] in severe obstructive sleep apnea. Moderate-severe obstructive sleep apnea was associated with a higher risk of lacunar infarcts. Obstructive sleep apnea had no association with cerebral microbleeds and an indeterminate association with perivascular spaces and subcortical infarcts due to insufficient data.

Assessing the effect of interaction between lifestyle and longitudinal changes in brain structure on sleep phenotypes

Longitudinal changes in brain structure and lifestyle can affect sleep phenotypes. However, the influence of the interaction between longitudinal changes in brain structure and lifestyle on sleep phenotypes remains unclear. Genome-wide association study dataset of longitudinal changes in brain structure was obtained from published study. Phenotypic data of lifestyles and sleep phenotypes were obtained from UK Biobank cohort. Using genotype data from UK Biobank, we calculated polygenetic risk scores of longitudinal changes in brain structure phenotypes. Linear/logistic regression analysis was conducted to evaluate interactions between longitudinal changes in brain structure and lifestyles on sleep duration, chronotype, insomnia, snoring and daytime dozing. Multiple lifestyle × longitudinal changes in brain structure interactions were detected for 5 sleep phenotypes, such as physical activity×caudate_age2 for daytime dozing (OR = 1.0389, P = 8.84 × 10-3) in total samples, coffee intake×cerebellar white matter volume_age2 for daytime dozing (OR = 0.9652, P = 1.13 × 10-4) in females. Besides, we found 4 overlapping interactions in different sleep phenotypes. We conducted sex stratification analysis and identified one overlapping interaction between female and male. Our results support the moderate effects of interaction between lifestyle and longitudinal changes in brain structure on sleep phenotypes, and deepen our understanding of the pathogenesis of sleep disorders.

The association between white matter hyperintensities of presumed vascular origin and disability is mediated by age: a population-based study in stroke-free older adults

BACKGROUND

Information on the association between disability and severity of white matter hyperintensities (WMH) among stroke-free individuals is limited. We aimed to assess this association in apparently healthy older adults.

METHODS

Following a population-based cross-sectional design, community-dwelling older adults received a brain MRI to grade WMH severity and the Functional Activities Questionnaire to assess the ability to perform activities of daily living. Demographics, clinical risk factors and other markers of cerebral small vessel disease were taken into consideration for analysis.

RESULTS

Unadjusted analysis showed a significant association between moderate-to-severe WMH and disability (p = 0.003) that was tempered by the effect of age. Causal mediation analysis showed that age took away 65.9% of the effect of WMH severity on disability. An interaction model showed that disability was higher only among subjects with moderate-to-severe WMH above the median age.

CONCLUSIONS

Increasing age mediates the probability of WMH-related disability in stroke-free individuals.

Antithrombotic therapy to prevent cognitive decline in people with small vessel disease on neuroimaging but without dementia

BACKGROUND

Cerebral small vessel disease is a progressive disease of the brain's deep perforating blood vessels. It is usually diagnosed based on lesions seen on brain imaging. Cerebral small vessel disease is a common cause of stroke but can also cause a progressive cognitive decline. As antithrombotic therapy is an established treatment for stroke prevention, we sought to determine whether antithrombotic therapy might also be effective in preventing cognitive decline in people with small vessel disease.

OBJECTIVES

To assess the effects of antithrombotic therapy for prevention of cognitive decline in people with small vessel disease on neuroimaging but without dementia.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Review Group's Specialised Register, and the Cochrane Stroke Group's Specialised Register; the most recent search was on 21 July 2021. We also searched MEDLINE, Embase, four other databases and two trials registries. We searched the reference lists of the articles retrieved from these searches. As trials with a stroke focus may include relevant subgroup data, we complemented these searches with a focussed search of all antithrombotic titles in the Cochrane Stroke Group database.  SELECTION CRITERIA: We included randomised controlled trials (RCT) of people with neuroimaging evidence of at least mild cerebral small vessel disease (defined here as white matter hyperintensities, lacunes of presumed vascular origin and subcortical infarcts) but with no evidence of dementia. The trials had to compare antithrombotic therapy of minimum 24 weeks' duration to no antithrombotic therapy (either placebo or treatment as usual), or compare different antithrombotic treatment regimens. Antithrombotic therapy could include antiplatelet agents (as monotherapy or combination therapy), anticoagulants or a combination.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all the titles identified by the searches. We assessed full texts for eligibility for inclusion according to our prespecified selection criteria, extracted data to a proforma and assessed risk of bias using the Cochrane tool for RCTs. We evaluated the certainty of evidence using GRADE. Due to heterogeneity across included participants, interventions and outcomes of eligible trials, it was not possible to perform meta-analyses.

MAIN RESULTS

We included three RCTs (3384 participants). One study investigated the effect of antithrombotic therapy in participants not yet on antithrombotic therapy; two studies investigated the effect of additional antithrombotic therapy, one in a population already taking a single antithrombotic agent and one in a mixed population (participants on an antithrombotic drug and antithrombotic-naive participants). Intervention and follow-up durations varied from 24 weeks to four years. Jia 2016 was a placebo-controlled trial assessing 24 weeks of treatment with DL-3-n-butylphthalide (a compound with multimodal actions, including a putative antiplatelet effect) in 280 Chinese participants with vascular cognitive impairment caused by subcortical ischaemic small vessel disease, but without dementia. There was very low-certainty evidence for a small difference in cognitive test scores favouring treatment with DL-3-n-butylphthalide, as measured by the 12-item Alzheimer's Disease Assessment Scale-Cognitive subscale (adjusted mean difference -1.07, 95% confidence interval (CI) -2.02 to -0.12), but this difference may not be clinically relevant. There was also very low-certainty evidence for greater proportional improvement measured with the Clinician Interview-Based Impression of Change-Plus Caregiver Input (57% with DL-3-n-butylphthalide versus 42% with placebo; P = 0.01), but there was no difference in other measures of cognition (Mini-Mental State Examination and Clinical Dementia Rating) or function. There was no evidence of a difference in adverse events between treatment groups. The SILENCE RCT compared antithrombotic therapy (aspirin) and placebo during four years of treatment in 83 participants with 'silent brain infarcts' who were on no prior antithrombotic therapy. There was very low-certainty evidence for no difference between groups across various measures of cognition and function, rates of stroke or adverse events. The Secondary Prevention of Subcortical Stroke Study (SPS3) compared dual antiplatelet therapy (clopidogrel plus aspirin) to aspirin alone in 3020 participants with recent lacunar stroke. There was low-certainty evidence of no effect on cognitive outcomes as measured by the Cognitive Abilities Screening Instruments (CASI) assessed annually over five years. There was also low-certainty evidence of no difference in the annual incidence of mild cognitive decline between the two treatment groups (9.7% with dual antiplatelet therapy versus 9.9% with aspirin), or the annual stroke recurrence rate (2.5% with dual antiplatelet therapy versus 2.7% with aspirin). Bleeding risk may be higher with dual antiplatelet therapy (hazard ratio (HR) 2.15, 95% CI 1.49 to 3.11; low certainty evidence), but there may be no significant increase in intracerebral bleeding risk (HR 1.52, 95% CI 0.79 to 2.93; low-certainty evidence). None of the included trials assessed the incidence of new dementia.

AUTHORS' CONCLUSIONS

We found no convincing evidence to suggest any clinically relevant cognitive benefit of using antithrombotic therapy in addition to standard treatment in people with cerebral small vessel disease but without dementia, but there may be an increased bleeding risk with this approach. There was marked heterogeneity across the trials and the certainty of the evidence was generally poor.

Validation of external and internal exposome of the findings associated to cerebral small vessel disease: A Mendelian randomization study

The exposome characterizes all environmental exposures and their impact on a disease. To determine the causally-associated components of the exposome for cerebral small vessel disease (CSVD), we performed mendelian randomization analysis of 5365 exposures on six clinical and subclinical CSVD measures. We found statistically significant evidence (FDR-corrected P < 0.05) that hypertension, high cholesterol, longer television-watching time, lower educational qualifications, younger age of first sexual intercourse, smoking, reduced pulmonary function, higher subjective overall health rating, and frequent tiredness were associated with increased risk of intracerebral hemorrhage or small vessel stroke. Adiposity, diabetes, frequent alcoholic drinks, higher white blood cell count and neutrophil count were significantly associated with higher risk of non-lobar hemorrhage or small vessel stroke, but not lobar hemorrhage. Hypertension, higher arm or leg fat-free mass and higher sitting height were significantly associated with higher white matter hyperintensities. The results were robust to sensitivity analyses and showed no evidence of horizontal pleiotropy. We also identified 41 exposures suggestively associated (uncorrected P < 0.05) with multiple CSVD measures as the "the CSVD exposome". This exposome-wide association study provides insight into CSVD development and prevention.

High Social Risk Influence Progression of White Matter Hyperintensities of Presumed Vascular Origin: A Prospective Study in Community-Dwelling Older Adults

BACKGROUND

Information on cerebrovascular consequences of high social risk, as determined by the social determinants of health, is limited. We sought to evaluate the impact of high social risk on the progression of white matter hyperintensities (WMHs) of presumed vascular origin.

METHODS

Following a longitudinal prospective study design, participants of the Atahualpa Project Cohort received baseline social risk determinations by means of social determinants of health components included in the Gijon's Social-Familial Evaluation Scale together with clinical interviews and brain magnetic resonance imagings. Those who also received follow-up brain magnetic resonance imaging at the end of the study were included. We used Poisson regression models adjusted for demographics, education levels and traditional cardiovascular risk factors to assess the incidence rate ratio of WMH progression according to the Gijon's Social-Familial Evaluation Scale score.

RESULTS

The study included 263 individuals aged ≥60 years (mean age, 65.7±6.2 years; 57% women). The Gijon's Social-Familial Evaluation Scale mean score was 8.9±2.2 points. Follow-up magnetic resonance imagings revealed WMH progression in 103 (39%) individuals after a mean follow-up of 6.5 years (SD±1.4 years). Poisson regression models showed increased WMH progression rate among individuals in the third tertile of the Gijon's Social-Familial Evaluation Scale score compared with those in the first tertile (incidence rate ratio, 1.65 [95% CI, 1.05-2.61]; P=0.032). Separate Poisson regression models using individual social determinants of health components showed that poor social relationships (incidence rate ratio, 1.39 [95% CI, 1.10-1.77]; P=0.006) and deficient support networks (incidence rate ratio, 1.79 [95% CI, 1.19-2.69]; P=0.005) were independently associated with WMH progression, whereas family situation, economic status, and housing did not.

CONCLUSIONS

Poor social relationships and deficient support networks were significantly associated with WMH progression in community-dwelling older adults living in a rural setting. Our findings may help planning cost-effective preventive policies to reduce progression of cerebral small vessel disease among vulnerable populations.

Poor Sleep Quality Associated With Enlarged Perivascular Spaces in Patients With Lacunar Stroke

Background and Objective

Enlarged perivascular spaces (EPVSs) are considered as an MRI marker of cerebral small vessel diseases and were reported to be associated with brain waste clearance dysfunction. A previous study found that interstitial fluid clearance in the mouse brain occurred mainly during sleep. However, the relationship between sleep quality and EPVS in humans has not been well-understood. Thus, we aimed to investigate the relationship between sleep and EPVS in humans.

Methods

This retrospective study was conducted in patients with lacunar stroke in the Neurology Department of Beijing Chaoyang Hospital. Patients with EPVS >10 on one side of the basal ganglia (BG) and white matter slice containing the maximum amount were defined as the BG-EPVS group and the white matter (WM)-EPVS group, respectively. Patients with EPVS <10 in the slice containing the maximum amount were defined as the control group. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI) including seven components, where a score of 6 or higher indicated poor sleep quality. Spearman's correlation analysis and the binary logistic regression analysis were performed to analyze the relationship between poor sleep quality and BG-EPVS and WM-EPVS, respectively.

Results

A total of 398 patients were enrolled in this study, including 114 patients in the BG-EPVS group and 85 patients in the WM-EPVS group. The proportion of poor sleep quality in the BG-EPVS group was higher than that in the control group (58.8 vs. 32.5%, p < 0.001). The score of PSQI, subjective sleep quality, sleep latency, sleep duration, and sleep efficiency were higher in the BG-EPVS group than that in the control group (p < 0.05). The proportion of poor sleep quality was also higher in the WM-EPVS group than that in the control group (50.6 vs. 35.3%, p = 0.031). The score of sleep duration and sleep disturbances was higher in the WM-EPVS group than that in the control group. Spearman's correlation analysis showed that poor sleep quality was positively associated with BG-EPVS (ρ = 0.264, p < 0.001) and WM-EPVS (ρ = 0.154, p = 0.044). The binary logistic regression analysis showed that poor sleep quality, longer sleep latency, and less sleep duration were independently related to BG-EPVS and poor sleep quality, less sleep duration, and more serious sleep disturbances were independently related to WM-EPVS after adjusting for confounders (P < 0.05).

Conclusion

Poor sleep quality was independently associated with EPVS in BG and WM.

Association of Excessive Daytime Sleepiness with Cerebral Small Vessel Disease in Community-Dwelling Older Adults

PURPOSE

Excessive daytime sleepiness (EDS) and cerebral small vessel disease (CSVD) are common problems among older adults; however, their association is not clear. The present study aimed to investigate the frequency of EDS in CSVD patients and the relationship between EDS and neuroimaging markers of CSVD.

PATIENTS AND METHODS

We conducted a cross-sectional study among 1076 community-dwelling older adults aged 55-85 years. EDS was measured using the Epworth Sleepiness Scale (ESS), and EDS was defined as an ESS score greater than 10. Binary logistic regression was performed to assess the association between EDS and neuroimaging markers of CSVD.

RESULTS

Of the 1076 participants (mean age: 65.58 ± 6.46 years, 60.5% female), the prevalence of EDS was 10.0%. EDS was more frequent in participants with CSVD than in the total sample (20.0% vs 10.0%, p <0.001). In fully adjusted models, EDS was significantly correlated with CSVD burden (OR = 1.39, 95% CI 1.16 to 1.68, p <0.001), the severity of white matter hyperintensities (WMH) (OR = 1.33, 95% CI 1.14 to 1.54, p <0.001), and presence of lacunes (OR = 2.47, 95% CI 1.53 to 4.00, p <0.001) but not with the presence of cerebral microbleeds (CMBs) (OR=1.54, 95% CI 0.92 to 2.56, p = 0.099) or severity of enlarged perivascular spaces (EPVS) in basal ganglia (OR = 1.16, 95% CI 0.70 to 1.92, p = 0.564).

CONCLUSION

We found a high frequency of EDS symptoms in CSVD individuals. Further, EDS was significantly associated with WMH, lacunes, and CSVD burden. Our findings further suggest patients with CSVD may exhibit abnormal sleep-wake patterns.

Neuropsychiatric symptoms and altered sleep quality in cerebral small vessel disease

BACKGROUND

Sleep disturbance and neuropsychiatric symptoms are common clinical symptoms of cerebral small vessel disease (CSVD), but the underlying mechanism is unclear. Here, we investigated the relationship between sleep quality and neuropsychiatric performance in patients with CSVD.

METHODS

A total of 30 patients with CSVD and 35 healthy controls (HCs) were recruited. The 13-item Beck Depression Inventory (BDI-13), Beck Anxiety Inventory (BAI), and Symptom Check List 90 (SCL90) were used to assess depression, anxiety, and other psychological symptoms, respectively. Sleep quality was assessed using Pittsburgh Sleep Quality Index (PSQI), and cognitive function was tested using Montreal Cognitive Assessment (MoCA).

RESULTS

When compared to the HC group, the patients with CSVD showed increased anxiety and neuropsychiatric symptoms, worse sleep quality, and impaired cognition (p < 0.05). The prevalence of comorbid poor sleep quality in the patients with CSVD was approximately 46%. The patients with CSVD with poor sleep quality also had more severe neuropsychiatric symptoms. After controlling for demographic variables, sex and anxiety significantly predicted sleep quality.

CONCLUSION

This study suggests that the prevalence of CSVD with poor sleep quality is high, and that sex and anxiety are independent risk factors for CSVD comorbid sleep quality.

Sleep Quality Mediates the Association Between Cerebral Small Vessel Disease Burden and Frailty: A Community-Based Study

Background: Physical frailty is a common problem among older adults which usually leads to adverse health outcomes. The imaging markers of cerebral small vessel disease (CSVD) are associated with frailty, but the underlying mechanisms remain unclear. The present study aimed to investigate the mediating role of sleep quality in the relationship between CSVD burden and frailty. Methods: We performed a cross-sectional study and enrolled community residents. Frailty and sleep quality were measured using the Fried frailty phenotype and the Pittsburgh Sleep Quality Index (PSQI), respectively. A multivariate linear regression analysis and a Bootstrap analysis were performed to examine the association among the key variables and the mediating role of sleep quality. Results: Of the 726 participants (mean age: 65.5 ± 6.5 years, 59.8% female), the numbers (percentages) of the frail, prefrail, and robust residents were 49 (6.7%), 310 (42.7%), and 367 (50.6%), respectively. After adjusting for covariates, the CSVD burden and PSQI score were significantly associated with the frailty score. In addition, sleep quality played a partial mediating role in the association between CSVD burden and physical frailty. The mediating effect was 21.9%. Conclusion: The present study suggests that sleep quality is a mediator of this association between CSVD and frailty in community-dwelling older adults. Improving sleep quality might be helpful to mitigate the risk of frailty in CSVD patients.

Association Between Sleep Quality and Falls: A Nationwide Population-Based Study from South Korea

Purpose

There are few large studies evaluating the association between sleep quality and the risk of falls. We aimed to determine the independent effect of poor sleep quality on an increased risk of falls using a large-sample dataset.

Methods

We conducted a retrospective, cross-sectional study using population-based data from the 2018 Korean Community Health Survey on 201,700 participants. Sociodemographic, mental health-related, and physical health-related variables as well as sleep quality evaluated by the Pittsburgh Sleep Quality Index (PSQI) were compared between 2499 fallers who have experienced at least one fall during the past 12 months and 199,201 non-fallers. Multivariable logistic regression was performed to identify sleep quality variables significantly associated with an increased risk of falls.

Results

Fallers had poorer sleep quality (PSQI score >5) and higher scores for global PSQI and individual PSQI components than did non-fallers (all p < 0.001). Multivariable logistic regression adjusted for potential confounders including socioeconomic, physical health-related, and mental health-related variables showed that an increased risk of falls was associated with poor sleep quality (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.19–1.42). Subgroup analyses by age revealed that poor sleep quality was significantly associated with an increased risk of falls in all three adult age groups. Multivariable logistic regression using the seven PSQI components revealed that an increased risk of falls was associated with short sleep duration (OR 1.14, CI 1.09–1.20), increased sleep disturbances (OR 1.30, CI 1.16–1.46), and increased daytime dysfunctions (OR 1.21, CI 1.08–1.13).

Conclusion

Poor sleep quality caused by short sleep duration may be a principal risk factor of falls in adult populations. Increased sleep disturbances and daytime dysfunctions may also contribute to an increased risk of falls. Our results have clinical and public health perspectives that increasing sleep duration and reducing daytime dysfunctions and sleep disturbances could mitigate unintentional falls.

Pre-stroke habitual prolonged sleep as a predictor for post-stroke sleep quality, stroke-related quality of life, and lifestyle values

BACKGROUND

Prolonged sleep is a higher stroke risk, but post-stroke prolonged sleep facilitates stroke recovery. No study has explored the relationship between pre- and post-stroke prolonged sleep and their involvement in stroke-related quality of life (QOL).This study aimed to clarify the role of pre- and post-stroke prolonged sleep in QOL and sleep quality during hospitalization.

METHODS

Fifty-one subacute stroke inpatients were enrolled. QOL was assessed by the Stroke and Aphasia QOL Scale-39-J. Sleep quality and lifestyle values were assessed by original questionnaires.

RESULTS

Patients in pre-stroke prolonged sleep > 8 h had a higher incidence of post-stroke poor sleep quality than those belonging to the normal or shorter hours (OR 5.33, 95% CI 1.30-21.84, p = 0.047). In addition, pre-stroke prolonged sleep was associated with lower scores of psychosocial QOL and lifestyle values of "accepting disability; caring about what other people think of what you do". In contrast, post-stroke prolonged sleep was associated with the lower risk of post-stroke poor sleep quality (OR 0.27, 95% CI 0.08-0.86, p = 0.045). Post-stroke high sleep quality had higher (better) scores of physical and energy QOL, and lifestyle values of "caring about what other people think of what you do; having some places to go out after discharge" compared with post-stroke poor sleep quality. Post-stroke prolonged sleep was derived from pre-stroke not prolonged sleep rather than pre-stroke prolonged sleep (p = 0.039, Chi-square test).

CONCLUSIONS

Pre-stroke prolonged sleep is associated with a higher incidence of post-stroke poor sleep quality and lower scores of QOL and lifestyle values after stroke.

Risks and Prognoses of Alzheimer's Disease and Vascular Dementia in Patients With Insomnia: A Nationwide Population-Based Study

This study aimed to investigate the risk and prognosis of Alzheimer's disease (AD) and vascular dementia (VaD) in patients with insomnia using the National Health Insurance Service database covering the entire population of the Republic of Korea from 2007 to 2014. In total, 2,796,871 patients aged 40 years or older with insomnia were enrolled, and 5,593,742 controls were matched using a Greedy digit match algorithm. Mortality and the rate of admission to a long-term care facility were estimated using multivariable Cox analysis. Of all patients with insomnia, 138,270 (4.94%) and 26,706 (0.96%) were newly diagnosed with AD and VaD, respectively. The incidence rate ratios for AD and VaD were 1.73 and 2.10, respectively, in patients with insomnia compared with those without. Higher mortality rates and long-term care facility admission rates were also observed in patients with dementia in the insomnia group. Known cardiovascular risk factors showed interactions with the effects of insomnia on the risk of AD and VaD. However, the effects of insomnia on the incidence of AD and VaD were consistent between the groups with and without cardiovascular risk factors. Insomnia is a medically modifiable and policy-accessible risk factor and prognostic marker of AD and VaD.

A Proposed Hypothesis on Dementia: Inflammation, Small Vessel Disease, and Hypoperfusion Is the Sequence That Links All Harmful Lifestyles to Cognitive Impairment

There is growing consensus that certain lifestyles can contribute to cognitive impairment and dementia, but the physiological steps that link a harmful lifestyle to its negative impact are not always evident. It is also unclear whether all lifestyles that contribute to dementia do so through the same intermediary steps. This article will focus on three lifestyles known to be risk factors for dementia, namely obesity, sedentary behavior, and insufficient sleep, and offer a unifying hypothesis proposing that lifestyles that negatively impact cognition do so through the same sequence of events: inflammation, small vessel disease, decline in cerebral perfusion, and brain atrophy. The hypothesis will then be tested in a recently identified risk factor for dementia, namely hearing deficit. If further studies confirm this sequence of events leading to dementia, a significant change in our approach to this debilitating and costly condition may be necessary, possible, and beneficial.

Sleep characteristics and white matter hyperintensities among midlife women

STUDY OBJECTIVES

Sleep disturbance is common among midlife women. Poor self-reported sleep characteristics have been linked to cerebrovascular disease and dementia risk. However, little work has considered the relation of objectively assessed sleep characteristics and white matter hyperintensities (WMHs), a marker of small vessel disease in the brain. Among 122 midlife women, we tested whether women with short or disrupted sleep would have greater WMH, adjusting for cardiovascular disease (CVD) risk factors, estradiol, and physiologically assessed sleep hot flashes.

METHODS

We recruited 122 women (mean age = 58 years) without a history of stroke or dementia who underwent 72 h of actigraphy to quantify sleep, 24 h of physiologic monitoring to quantify hot flashes; magnetic resonance imaging to assess WMH; phlebotomy, questionnaires, and physical measures (blood pressure, height, and weight). Associations between actigraphy-assessed sleep (wake after sleep onset and total sleep time) and WMH were tested in linear regression models. Covariates included demographics, CVD risk factors (blood pressure, lipids, and diabetes), estradiol, mood, and sleep hot flashes.

RESULTS

Greater actigraphy-assessed waking after sleep onset was associated with more WMH [B(SE) = .008 (.002), p = 0.002], adjusting for demographics, CVD risk factors, and sleep hot flashes. Findings persisted adjusting for estradiol and mood. Neither total sleep time nor subjective sleep quality was related to WMH.

CONCLUSIONS

Greater actigraphy-assessed waking after sleep onset but not subjective sleep was related to greater brain WMH among midlife women. Poor sleep may be associated with brain small vessel disease at midlife, which can increase the risk for brain disorders.

Eating Habits and Sleep Quality during the COVID-19 Pandemic in Adult Population of Ecuador

Confinement due to COVID-19 has brought important changes in people’s lives as well as in their eating and resting habits. In this study we aimed at exploring the eating habits and sleep quality of the adult population of Ecuador during the mandatory confinement due to the COVID-19 pandemic. This is a cross-sectional study, which used an online survey that included questions about eating habits and sleeping habits in adults (n = 9522) between 18–69 years old. The Pittsburg sleep quality questionnaire validated for the Hispanic population was used, and questions about dietary habits. The statistical test Chi-square statistical test was used to analyze the data. The results show that sleep quality differs according to sex, being worse in women, both in all components of sleep quality and in the total score (p < 0.001). Women had greater changes in the habitual consumption of food compared to men (24.24% vs. 22.53%), and people between 18 and 40 years of age decreased their food consumption in relation to people >40 years (24.06% vs. 17.73%). Our results indicate that mandatory confinement due to the COVID-19 pandemic in Ecuador has generated changes in the eating habits and sleep quality in the adult population sampled, and these changes are more noticeable in women and young adults. These changes offer an important alert for the health system and further, advice for the implementation of future public health policies.

Sleep quality deterioration in middle-aged and older adults living in a rural Ecuadorian village severely struck by the SARS-CoV-2 pandemic. A population-based longitudinal prospective study

Study objectives

This study assessed changes in sleep quality before and after the peak of the SARS-CoV-2 pandemic in community-dwellers enrolled in the Atahualpa Project.

Methods

Atahualpa residents aged ≥40 were eligible if they had a Pittsburgh Sleep Quality Index (PSQI) nine months before the pandemic and a lateral flow-based test for identification of SARS-CoV-2 antibodies during the peak of the pandemic. Six months later, individuals completed a follow-up PSQI. The independent relationship between SARS-CoV-2 infection and deterioration in sleep quality was assessed by fitting logistic mixed models for longitudinal data.

Results

Of 639 participants (mean age at baseline: 59±12.8 years), 325 (51%) had SARS-CoV-2 antibodies. A total of 185 (29%) individuals at baseline and 311 (49%) at follow-up were poor sleepers (p<0.001). Mixed logistic regression models demonstrated a significant increase in poor sleepers at follow-up (OR: 2.85; 95% C.I.: 2.16 – 3.75), which was more marked among SARS-CoV-2 seropositive subjects (OR: 3.8; 95% C.I.: 2.48 – 5.81). The adjusted proportion of poor sleepers increased from 29% to 56.2% (95% C.I.: 50.9 – 61.6%) among SARS-CoV-2 seropositive individuals, but only to 40.7% (95% C.I.: 35.3 – 46.1%) in their seronegative counterparts (p<0.001). Likewise, progression from a good to a poor sleeper status was higher among seropositive individuals than in their seronegative counterparts (38.1% versus 22.3%; p<0.001), after adjusting for relevant covariates.

Conclusions

This study shows a deleterious effect of SARS-CoV-2 in sleep quality. An effect of SARS-CoV-2 in disrupting sleep-related pathways cannot be ruled out.

The prospective association of objectively measured sleep and cerebral white matter microstructure in middle-aged and older persons

STUDY OBJECTIVES

Poor sleep may destabilize axonal integrity and deteriorate cerebral white matter. In middle-aged and older adults sleep problems increase alongside structural brain changes, but the temporal relation between these processes is poorly understood. We studied longitudinal associations between sleep and cerebral white matter microstructure.

METHODS

One thousand one persons (59.3 ± 7.9 years, 55% women) were followed across 5.8 years (3.9-10.8). Total sleep time (TST, hours), sleep efficiency (SE, percentage), sleep onset latency (SOL, minutes), and wake after sleep onset (WASO, minutes) were measured at baseline using a wrist-worn actigraph. White matter microstructure (global and tract-specific fractional anisotropy [FA] and mean diffusivity [MD]) was measured twice with diffusion tensor imaging (DTI).

RESULTS

Poor sleep was associated with worse white matter microstructure up to 7 years later but did not predict trajectories of DTI over time. Longer TST was associated with higher global FA (β = 0.06, 95% CI: 0.01 to 0.12), but not with MD. Persons with higher SE had higher global FA (β = 0.01, 95% CI: 0.002 to 0.01) and lower MD (β = -0.01, 95% CI: -0.01 to -0.0004). Consistently, those with more WASO had lower global FA (β = -0.003, 95% CI: -0.005 to -0.001) and higher MD (β = 0.002, 95% CI: 0.0004 to 0.004). Global findings seemed to be driven by microstructural alterations in the cingulum, anterior forceps of corpus callosum, projection and association tracts.

CONCLUSIONS

Middle-aged and older persons with more WASO, lower SE and shorter TST have worse microstructure of cerebral white matter. Microstructural alterations are most pronounced projection and association tracts, in the cingulum, and in the anterior forceps of corpus callosum.

Relationship between rosacea and sleep

Rosacea is a chronic facial skin disease involved in neurovascular dysregulation and neurogenic inflammation. Behavioral factors such as stress, anxiety, depression and sleep were identified to be associated with other inflammatory skin diseases. Few studies have reported sleep status in rosacea. Aiming to investigate the relationship between rosacea and sleep, a case-control survey was conducted, enrolling 608 rosacea patients and 608 sex- and age-matched healthy controls. Sleep quality was assessed through the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Diagnosis and severity grading of rosacea were evaluated under the standard guidelines of the National Rosacea Society. More rosacea patients (52.3%, n = 318) suffered poor sleep quality (PSQI, >5) than the healthy controls (24.0%, n = 146), displaying a much higher PSQI score (rosacea vs control, 6.20 vs 3.95). There was a strong association between sleep quality and rosacea (odds ratio [OR], 3.525; 95% confidence interval [CI], 2.759-4.519). Moreover, the severity of rosacea was also associated with sleep quality (OR, 1.847; 95% CI, 1.332-2.570). Single nucleotide polymorphisms in hydroxytryptamine receptor 2A and adrenoceptor-β1 genes, which are associated with sleep behaviour, were detected and revealed to be associated with rosacea. Furthermore, the LL-37-induced rosacea-like phenotype and sleep-deprivation mice models were applied, revealing that sleep deprivation aggravated the rosacea-like phenotype in mice, with higher expression of matrix metallopeptidase 9, Toll-like receptor 2, cathelicidin antimicrobial peptide and vascular endothelial growth factor. In conclusion, rosacea patients presented poorer sleep quality, as well as a higher propability of genetic background with sleep disturbance. In addition, poor sleep might aggravate rosacea through regulating inflammatory factors, contributing to a vicious cycle in the progression of disease.

Non breathing-related sleep fragmentation and imaging markers in patients with atherosclerotic cerebral small vessel disease (CSVD): a cross-sectional case-control study

Background

Sleep fragmentation was shown to be positively associated with cognitive impairment in patients with cerebral small vessel disease (CSVD); however, the underlying mechanisms are not well characterized. In this study, we sought to clarify this issue by investigating the relationship between non breathing-related sleep fragmentation and brain imaging markers in patients with CSVD.

Methods

Eighty-four CSVD patients and 24 age- and sex-matched healthy controls were prospectively recruited. All subjects underwent 3.0 T superconducting magnetic resonance imaging and overnight polysomnography. Polysomnography parameters including sleep onset latency (SOL), total sleep time (TST); sleep efficiency (SE), wake after sleep onset (WASO), percentage of each sleep stage (N1, N2, N3 and rapid eye movement [REM]), arousal index (ArI), periodic limb movement in sleep index (PLSMI), and periodic limb movement related arousal index (PLMAI) were compared between CSVD patients and healthy controls. The relationship between arousal index and CSVD markers was explored in the CSVD group.

Results

On polysomnography, CSVD patients showed significantly higher ArI, WASO, PLSMI, and PLMAI, and lower sleep efficiency and N^− 3 ratio compared to healthy controls (p < 0.05). On ordinal logistic regression, higher ArI showed a positive association with the severity of periventricular white matter hyperintensity (odds ratio [OR] 1.121, 95% confidence interval [CI] 0.138–2.185) and perivascular space (OR 2.108, 95% CI 1.032–4.017) in CSVD patients, after adjusting for potential confounding variables.

Conclusions

These preliminary results indicate that non breathing-related sleep fragmentation is common and related to the pathological markers of CSVD patients. Future prospective research is required to determine the causal relationship between sleep parameters and CSVD pathology.

Cerebrovascular Correlates of Dementia in Community-Dwelling Older Adults Living in Rural Communities - The Three Villages Study. Rationale and Protocol of a Population-Based Prospective Cohort Study

BACKGROUND

Despite the assumption that dementia is increasing in rural areas of Latin America, there is no information on the burden and risk factors leading to dementia in these settings.

AIMS

To assess prevalence and incidence of dementia, and its cerebrovascular correlates in an established cohort of community-dwelling older adults living in rural Ecuador, and to explore the impact of dementia on functional disability and the role of the social determinants of health in the above-mentioned relationships.

DESIGN

Population-based, cohort study with cross-sectional and longitudinal components. Baseline clinical interviews will focus on the assessment of cognitive performance and dementia by means of the clinical dementia rating scale (CDRS). Functional disability and social determinants of health will be correlated with CDRS scores. In addition, participants will undergo interviews and procedures to assess cardiovascular risk factors and signatures of brain damage, cerebral small vessel disease, and other stroke subtypes. The CDRS and the Functional Activities Questionnaire will be administered every year to assess the rate of incident dementia and the severity of functional disability. Neuroimaging studies will be repeated at the end of the study (5 years) to assess the impact of newly appeared cerebral and vascular lesions on cognitive decline.

COMMENT

This study will allow determine whether cerebrovascular diseases are in the path of dementia development in these rural settings. This may prove cost-effective for the development of preventive strategies aimed to control modifiable factors and reduce disability in patients with dementia living in underserved populations.

Chronic Insomnia Is Associated with Higher Circulating Interleukin-8 in Patients with Atherosclerotic Cerebral Small Vessel Disease

OBJECTIVE

Chronic inflammatory responses and leukocyte infiltration are classical pathological features of cerebral small vessel disease (CSVD). To date, limited evidence of a relationship between chronic insomnia and inflammatory responses in patients with CSVD has been uncovered. The purpose of the present study was to investigate the potential relationship between chronic insomnia and pro-inflammatory cytokine levels in patients with atherosclerotic CSVD (A-CSVD).

METHODS

In total, 76 A-CSVD patients with or without chronic insomnia (CI) confirmed using magnetic resonance (MR) were prospectively recruited. Overnight polysomnography (PSG) was performed and serum levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), IL-6, IL-17A, IL-8, and IL-12 assessed. Cytokine levels were compared between CSVD+CI (study group) and CSVD without CI (control group) patients, and the correlations between PSG parameters and cytokine levels were explored in all patients via multiple linear regression analyses.

RESULTS

The serum IL-8 level of the study group (12.3±4.4 pg/mL) was significantly higher than that of the control group (7.5±2.2 pg/mL; P<0.05). PSG measurements showed that patients in the study group had significantly higher sleep onset latency (SOL), arousal index (ArI) and wake after sleep onset (WASO) as well as lower total sleep time (TST), sleep efficiency (SE) and stage 3 NREM sleep (N-3) ratio, compared with the control group (P<0.05). Multiple linear regression analyses led to the identification of ArI (β=0.026, P<0.05) and TST (β=-0.054, P<0.05) as significant positive and negative predictors of the IL-8 level, respectively.

CONCLUSION

Chronic insomnia, in particular, sleep fragmentation and short sleep duration, may be involved in promotion of serum IL-8 expression in patients with atherosclerotic CSVD.

On the Association Between Social Determinants of Health and Disability in Stroke-Free Older Adults Living in Rural Settings. The Three Villages Study

BACKGROUND

High social risk, as quantified by the social determinants of health (SDH), may lead to disability. This association has not been well explored in remote settings. Using the three Villages Study cohort, we assessed the association between SDH and disability among stroke-free older adults living in a rural Ecuadorian community.

METHODS

SDH were measured by the use of the Gijon Scale and disability by the Functional Activities Questionnaire. All participants had a brain MRI to assess subclinical biomarkers of cerebral small vessel disease. Multivariate models were fitted to assess the association between components of SDH and disability, after adjusting for covariates of interest.

RESULTS

The mean age of 478 enrolled individuals was 70.1 ± 8 years (59% women). High social risk was observed in 220 (46%) individuals and disability in 222 (46%). There was an almost direct linear relationship between SDH and disability, after taking into account the effect of age. A generalized linear model, adjusted for all included covariates, showed an independent association between social risk and disability (P < .001). In addition, multivariate models showed that independent SDH components more strongly associated with disability were worse support networks and social relationships. In contrast, the single SDH component not associated with disability was the economic status.

CONCLUSIONS

This study showed a robust association between SDH and disability. Economic needs were surpassed by other components of SDH. This knowledge will help to develop strategies for the control of factors that may be in the path for disability among older adults living in rural settings.

Sleep Quality and Cognitive Function in Type 1 Diabetes: Findings From the Study of Longevity in Diabetes (SOLID)

STUDY OBJECTIVE

The objective was to examine the association between sleep quality and global and domain-specific cognitive function among older individuals with type 1 diabetes (T1D).

METHODS

We evaluated 695 individuals with T1D aged 60 years or above who participated in the baseline assessment of the Study of Longevity in Diabetes (SOLID), which captured subjective sleep quality (Pittsburgh Sleep Quality Index) and global and domain-specific (language, executive function, episodic memory, and simple attention) cognitive function. Multivariable linear regressions estimated the associations between sleep quality quartiles and overall and domain-specific cognitive function adjusting for age, sex, race/ethnicity, education, depressive symptoms, and severe hypoglycemic episodes. Sensitivity analyses examined the associations between aspects of sleep quality and global cognitive function.

RESULTS

The worst sleep quality quartile was associated with lower global cognition (β=-0.08; 95% confidence interval: -0.17, -0.01) and lower executive function (β=-0.17, 95% confidence interval: -0.30, -0.03) compared with the best quartile of sleep quality adjusting for demographics and comorbidities. Sleep quality was not associated with language, episodic memory, or simple attention. Sleep medications and daytime dysfunction were most strongly associated with global cognition.

CONCLUSION

Our results suggest that sleep quality may be a modifiable risk factor for global cognitive function and executive function among elderly individuals with T1D.

Neuroimaging consequences of cerebral small vessel disease in patients with obstructive sleep apnea-hypopnea syndrome

OBJECTIVE

This study aimed to investigate the association between severity of obstructive sleep apnea-hypopnea syndrome (OSAHS) and the neuroimaging consequences of cerebral small vessel disease (SVD).

METHODS

Patients with OSAHS and age- and gender-matched healthy control subjects completed the mini-mental state examination and underwent an evoked-related potential study and overnight polysomnographic monitoring. Magnetic resonance imaging (MRI) was performed to detect markers of silent cerebral SVD, including Virchow-Robin spaces (VRS) rated on a five-point scale, white matter lesions, lacunar infarcts, and deep microbleeds. Multinomial logistic regression models were used to examine the associations of the apnea-hypopnea index (AHI) and arousal index (AI) values, mean oxyhemoglobin saturation, the duration of snoring history, and MRI markers of small vessel disease with the incidence of enlarged VRS.

RESULTS

The study included 72 patients with severe OSAHS and 53 volunteers without OSAHS. The duration of snoring history ranged from 5 to 22 years in the OSAHS group. Smaller P3 amplitudes at Cz were found in OSAHS patients than control subjects (p < .05), which is associated with neurocognitive impairment. Enlarged VRS were more prevalent in the basal ganglia and centrum semiovale of patients with OSAHS than in the control group. No significant between-group differences were observed in the number of white matter lesions, lacunar infarcts, and deep microbleeds. Enlarged VRS were positively correlated with AHI and AI values in the OSAHS group (r = .63, p < .001; r = .55, p < .001, respectively).

CONCLUSIONS

Silent cerebral SVD was more prevalent in patients with OSAHS than in the controls. Enlarged VRS observed in the basal ganglia and centrum semiovale were positively correlated with severity of OSAHS, which may contribute to cognitive impairment.

Sleep and brain morphological changes in the eighth decade of life

OBJECTIVE

Sleep is important for brain health. We analysed associations between usual sleep habits and magnetic resonance imaging (MRI) markers of neurodegeneration (brain atrophy), vascular damage (white matter hyperintensities, WMH) and waste clearance (perivascular spaces, PVS) in older community-dwelling adults.

METHOD

We collected self-reported usual sleep duration, quality and medical histories from the Lothian Birth Cohort 1936 (LBC1936) age 76 years and performed brain MRI. We calculated sleep efficiency, measured WMH and brain volumes, quantified PVS, and assessed associations between sleep measures and brain markers in multivariate models adjusted for demographic and medical history variables.

RESULTS

In 457 subjects (53% males, mean age 76 ± 0.65 years), we found: brain and white matter loss with increased weekend daytime sleep (β = -0.114, P = 0.03; β = -0.122, P = 0.007 respectively), white matter loss with less efficient sleep (β = 0.132, P = 0.011) and PVS increased with interrupted sleep (OR 1.84 95% CI, P = 0.025).

CONCLUSION

Cross-sectional associations of sleep parameters with brain atrophy and more PVS suggest adverse relationships between usual sleep habits and brain health in older people that should be evaluated longitudinally.

Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment

PURPOSE OF REVIEW

This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke.

RECENT FINDINGS

Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke.

SUMMARY

Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.

Sleep complaints and cerebral white matter: A prospective bidirectional study

Sleep complaints and brain changes co-occur in older adulthood, but the temporal relation between these processes is poorly understood. Poor sleep may destabilize axonal integrity and deteriorate white matter, but white matter pathology can also precede sleep complaints. Our objective was to explore a prospective, possibly bi-directional association between subjective sleep complaints and micro- and macro-structural properties of cerebral white matter. We assessed sleep complaints and brain magnetic resonance imaging at two time-points (2006-2008 and 2011-2014) in a population-based cohort including 2529 participants (56 ± 6 years old, 55% women). Sleep complaints were assessed with the Pittsburgh Sleep Quality Index. White matter lesion (WML) volume was assessed from fluid-attenuated inversion recovery images and global and tract-specific white matter microstructural integrity with diffusion tensor imaging. Sleep complaints at baseline were not associated with changes in WML volume or global white matter microstructure. In tract-specific analyses, however, sleep complaints were associated with reduced microstructural integrity in two white matter tracts projecting to the brainstem, but only when uncorrected for multiple testing. Likewise, we found no evidence for the reverse association; micro- or macro-structural properties of white matter were not related to changes in sleep complaints over time. This study provides evidence against the hypothesis that sleep complaints lead to white matter changes in the aging brain, and shows that white matter properties do not underlie sleep complaints in older persons. As subjective sleep complaints increase in later life, it is important to demonstrate that these are not etiologically related to cerebral white matter pathology.

The influence of non-breathing-related sleep fragmentation on cognitive function in patients with cerebral small vessel disease

BACKGROUND

Cognitive impairment in patients with cerebral small vessel disease (CSVD) is common, but the pathogenic mechanism is not well understood. The situation of non-breathing-related sleep fragmentation in CSVD patients and its influence on cognitive impairment is not clear. The aim of this study was to investigate the influence of non-breathing-related sleep fragmentation on cognitive function in patients with CSVD.

METHODS

A group of 89 CSVD patients without breathing-related sleep disorders in the Department of Neurology, Third Affiliated Hospital of Sun Yat-sen University was enrolled. The patients underwent magnetic resonance scan, polysomnography, cognitive function evaluation using Montreal Cognitive Assessment scale (MoCA), and Mini-Mental State Examination. The patients were assigned to study group (arousal index [ArI] ≥26.8/hour) or control group (ArI <26.8/hour) based on the average level of ArI (mean =26.8, SD =7.5) at night, and the cognitive function of the patients in the two groups was analyzed.

RESULTS

The total MoCA score, the subscale scores of visuospatial ability and delayed recall in the study group were significantly lower than that in the control group (P<0.05). The cognitive impairment measured by MoCA was positively related to ArI level and %N-3 sleep according to the results of logistic regression (P<0.05).

CONCLUSION

Non-breathing-related sleep fragmentation is associated with cognitive impairment in CSVD patients, especially executive function and delayed recall ability.

Sleep quality correlates with the carotid intima-media thickness in stroke-free community-dwelling adults living in rural Ecuador. The Atahualpa Project

BACKGROUND/OBJECTIVES

Evidence of an association between sleep disorders and extracranial atherosclerosis is limited and has not been studied in remote rural settings, where living conditions and cardiovascular risk factors are different than in urban centers. We assessed the relationship between the carotid intima-media thickness (cIMT) and sleep quality in stroke-free individuals aged ≥40 years living in rural Ecuador.

METHODS

Applying a population-based study design, participants underwent face-to-face interviews using the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and sonographic examinations for measurement of the carotid intima-media thickness (cIMT). The association between the cIMT and sleep quality (as the dependent variable) was assessed by means of generalized linear models, adjusted for relevant confounders.

RESULTS

The mean age of 561 participants was 60.4 ± 12.6 years (58% women). The mean PSQI was 4.6 ± 2.2 points. Of those, 79 (14%) individuals had an increased cIMT (>1 mm). A model adjusted for demographics showed a significant association between increased cIMT and the PSQI score (β: 0.602; 95% C.I.: 0.027-1.177; p = 0.040). This relationship was reduced when cardiovascular risk factors were added to the model (β: 0.514; 95% C.I.: -0.072 - 1.101; p = 0.086). When the model was adjusted for demographics and psychological distress, the association between increased cIMT and the PSQI score became significant (β: 0.573; 95% C.I.: 0.013-1.133; p = 0.045). In addition, both symptoms of depression (p = 0.032) and anxiety (p < 0.001) remained independently significant.

CONCLUSIONS

This study shows an association between increased cIMT and the PSQI score, which is, at least, partly mediated by manifestations of psychological distress.

Understanding the direction of the relationship between white matter hyperintensities of vascular origin, sleep quality, and chronic kidney disease-Results from the Atahualpa Project

OBJECTIVE

The burden of cerebral small vessel disease, sleep disorders, and chronic kidney disease is on the rise in remote rural settings. However, information on potential links between these conditions is limited. We aimed to assess the relationships between these conditions in community-dwelling older adults living in rural Ecuador.

PATIENTS AND METHODS

Atahualpa residents aged ≥60 years were offered a brain MRI. A venous blood sample was obtained for serum creatinine determination. Baseline interviews and procedures were directed to assess demographics, cardiovascular risk factors, and sleep quality. Using generalized structural equation modeling (GSEM), we assessed the associations between white matter hyperintensities (WMH) of vascular origin, sleep quality and kidney function, as well as the directions of the relationships between these variables.

RESULTS

Of 423 candidates, 314 (74%) were enrolled. Moderate-to-severe WMH were noticed in 74 (24%) individuals, poor sleep quality in 101 (31%), and moderate-to-severe chronic kidney disease in 28 (9%). GSEM showed that the direction of the effect was from kidney function to WMH and from the latter to sleep quality. Of independent variables investigated, worse kidney function was associated with age, high glucose levels and male sex. WMH was associated with cholesterol blood levels, blood pressure, level of education and severe edentulism. Poor sleep quality was associated with poor physical activity.

CONCLUSION

This population based study shows that chronic kidney disease is associated with increased severity of WMH, which, in turn, is associated with a poor sleep quality.

Perivascular spaces, glymphatic dysfunction, and small vessel disease

Cerebral small vessel diseases (SVDs) range broadly in etiology but share remarkably overlapping pathology. Features of SVD including enlarged perivascular spaces (EPVS) and formation of abluminal protein deposits cannot be completely explained by the putative pathophysiology. The recently discovered glymphatic system provides a new perspective to potentially address these gaps. This work provides a comprehensive review of the known factors that regulate glymphatic function and the disease mechanisms underlying glymphatic impairment emphasizing the role that aquaporin-4 (AQP4)-lined perivascular spaces (PVSs), cerebrovascular pulsatility, and metabolite clearance play in normal CNS physiology. This review also discusses the implications that glymphatic impairment may have on SVD inception and progression with the aim of exploring novel therapeutic targets and highlighting the key questions that remain to be answered.

Associations between self-reported sleep quality and white matter in community-dwelling older adults: A prospective cohort study

Both sleep disturbances and decline in white matter microstructure are commonly observed in ageing populations, as well as in age‐related psychiatric and neurological illnesses. A relationship between sleep and white matter microstructure may underlie such relationships, but few imaging studies have directly examined this hypothesis. In a study of 448 community‐dwelling members of the Whitehall II Imaging Sub‐Study aged between 60 and 82 years (90 female, mean age 69.2 ± 5.1 years), we used the magnetic resonance imaging technique diffusion tensor imaging to examine the relationship between self‐reported sleep quality and white matter microstructure. Poor sleep quality at the time of the diffusion tensor imaging scan was associated with reduced global fractional anisotropy and increased global axial diffusivity and radial diffusivity values, with small effect sizes. Voxel‐wise analysis showed that widespread frontal‐subcortical tracts, encompassing regions previously reported as altered in insomnia, were affected. Radial diffusivity findings remained significant after additional correction for demographics, general cognition, health, and lifestyle measures. No significant differences in general cognitive function, executive function, memory, or processing speed were detected between good and poor sleep quality groups. The number of times participants reported poor sleep quality over five time‐points spanning a 16‐year period was not associated with white matter measures. In conclusion, these data demonstrate that current sleep quality is linked to white matter microstructure. Small effect sizes may limit the extent to which poor sleep is a promising modifiable factor that may maintain, or even improve, white matter microstructure in ageing. Hum Brain Mapp 38:5465–5473, 2017. © 2017 Wiley Periodicals, Inc.

Relationship between obstructive sleep apnea and neuroimaging signatures of cerebral small vessel disease in community-dwelling older adults. The Atahualpa Project

BACKGROUND/OBJECTIVES

Evidence of a relationship between obstructive sleep apnea (OSA) and neuroimaging signatures of cerebral small vessel disease (SVD) is limited. The present study aimed to evaluate this association in older adults living in rural Ecuador, where small vessel disease is a major pathogenetic mechanism underlying stroke.

METHODS

A representative random sample of Atahualpa residents aged ≥60 years enrolled in the Atahualpa Project neuroimaging substudy underwent a single-night diagnostic polysomnography. We evaluated whether OSA associates with severity of white matter hyperintensities (WMH), silent lacunar infarctions and deep cerebral microbleeds, using multivariate models adjusted for relevant confounders.

RESULTS

Of 351 candidates, 104 (30%) were randomly selected. Of these, 97 individuals (mean age 72.3 ± 7 years, 65% women) had adequate recordings and were included. Mean apnea/hypopnea index was 13.8 ± 14.1 episodes per hour; 27 persons (28%) had ≥15 episodes per hour and were considered to have moderate-to-severe OSA. Moderate-to-severe WMH were noticed in 25 individuals (25.8%), silent lacunar infarctions in 22 (22.7%) and deep cerebral microbleeds in 12 (12.4%). In multivariate models, OSA was associated with moderate-to-severe WMH (OR: 3.94; 95% C.I.: 1.09-14.97; p = 0.037), but not with silent lacunar infarctions (p = 0.195) or deep cerebral microbleeds (p = 0.405). A linear regression model confirmed the independent association between the apnea/hypopnea index and moderate-to-severe WMH (β: -7.14; 95% C.I.: -13.6 to -0.69; p = 0.031).

CONCLUSIONS

Individuals with moderate-to-severe OSA are almost four times more likely to have diffuse subcortical damage of vascular origin than those with none-to-mild OSA, independently of demographics and cardiovascular risk factors.