EEG and autonomic response pattern during waking and sleep stages

Updated Review of the Acoustic Modulation of Sleep: Current Perspectives and Emerging Concepts

With growing interest in the use of acoustic stimuli in sleep research and acoustic interventions used therapeutically for sleep enhancement, there is a need for an overview of the current lines of research. This paper summarizes the various ways to use acoustic input before sleep or stimulation during sleep. It thereby focuses on the respective methodological requirements, advantages, disadvantages, potentials and difficulties of acoustic sleep modulation. It highlights differences in subjective and objective outcome measures, immediate and whole night effects and short versus long term effects. This recognizes the fact that not all outcome parameters are relevant in every research field. The same applies to conclusions drawn from other outcome dimensions, consideration of mediating factors, levels of stimulation processing and the impact of inter-individual differences. In addition to the deliberate influences of acoustic input on sleep, one paragraph describes adverse environmental acoustic influences. Finally, the possibilities for clinical and basic research-related applications are discussed, and emerging opportunities are presented. This overview is not a systematic review but aims to present the current perspective and hence summarizes the most up-to-date research results and reviews. This is the first review providing a summary of the broad spectrum of possibilities to acoustically influence sleep.

Can the Orexin Antagonist Suvorexant Preserve the Ability to Awaken to Auditory Stimuli While Improving Sleep?

STUDY OBJECTIVES

The safety profile of the dual orexin receptor antagonists (DORAs) are currently unknown with regard to nocturnal responsivity among people with insomnia. We compared the auditory awakening thresholds (AATs) of the DORA suvorexant (10 and 20 mg) versus placebo in 12 individuals with DSM-5 insomnia.

METHODS

The study used a double-blind, placebo-controlled, three-way crossover design. Participants were randomly assigned to a treatment sequence that included placebo, suvorexant 10 mg, and suvorexant 20 mg. At the time of maximum drug concentration, auditory tones were played during stable stage N2 sleep. Tones increased by 5-decibel (db) increments until the participant awakened. The db at awakening was recorded as the AAT and compared between conditions. The proportion of awakenings higher than 85 db was also compared between conditions. Finally, sensitivity analyses were also conducted using surrounding thresholds (80 db and 90 db).

RESULTS

The mean AAT did not differ significantly between either dose of suvorexant compared to placebo. Moreover, the proportions of individuals who remained asleep at the AAT 85 db cutoff did not differ across conditions. In addition, wake after sleep onset decreased and total sleep time increased in the suvorexant 20 mg condition compared to placebo.

CONCLUSIONS

Suvorexant (10 and 20 mg) preserved the ability to respond to nocturnal stimuli, whereas the 20-mg dose improved the sleep of people with insomnia. This suggests that DORAs such as suvorexant can effectively treat insomnia while allowing patients to awaken to nocturnal stimuli in the environment.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: A Phase IV 3-Way Double-blind, Randomized, Crossover Study to Compare the Awakening Threshold Effects (Responsivity) of Belsomra 10 mg and 20 mg to Placebo in Non-elderly Insomniacs; Identifier NCT03312517; URL: https://clinicaltrials.gov/ct2/show/NCT03312517.

CITATION

Drake CL, Kalmbach DA, Cheng P, Roth T, Tran KM, Cuamatzi-Castelan A, Atkinson R, SinghM, Tonnu CV, Fellman-Couture C. Can the orexin antagonist suvorexant preserve the ability to awaken to auditory stimuli while improving sleep? J Clin Sleep Med. 2019;15(9):1285-1291.

Enhanced awakening probability of repetitive impulse sounds

In the present study relations between the level of impulse sounds and the observed proportion of behaviorally confirmed awakening reactions were determined. The sounds (shooting sounds, bangs produced by door slamming or by container transshipment, aircraft landings) were presented by means of loudspeakers in the bedrooms of 50 volunteers. The fragments for the impulse sounds consisted of single or multiple events. The sounds were presented during a 6-h period that started 75 min after the subjects wanted to sleep. In order to take account of habituation, each subject participated during 18 nights. At equal indoor A-weighted sound exposure levels, the proportion of awakening for the single impulse sounds was equal to that for the aircraft sounds. The proportion of awakening induced by the multiple impulse sounds, however, was significantly higher. For obtaining the same rate of awakening, the sound level of each of the successive impulses in a fragment had to be about 15-25 dB lower than the level of one single impulse. This level difference was largely independent of the degree of habituation. Various explanations for the enhanced awakening probability are discussed.

Effects of train noise and vibration on human heart rate during sleep: an experimental study

OBJECTIVES

Transportation of goods on railways is increasing and the majority of the increased numbers of freight trains run during the night. Transportation noise has adverse effects on sleep structure, affects the heart rate (HR) during sleep and may be linked to cardiovascular disease. Freight trains also generate vibration and little is known regarding the impact of vibration on human sleep. A laboratory study was conducted to examine how a realistic nocturnal railway traffic scenario influences HR during sleep.

DESIGN

Case-control.

SETTING

Healthy participants.

PARTICIPANTS

24 healthy volunteers (11 men, 13 women, 19-28 years) spent six consecutive nights in the sleep laboratory.

INTERVENTIONS

All participants slept during one habituation night, one control and four experimental nights in which train noise and vibration were reproduced. In the experimental nights, 20 or 36 trains with low-vibration or high-vibration characteristics were presented.

PRIMARY AND SECONDARY OUTCOME MEASURES

Polysomnographical data and ECG were recorded.

RESULTS

The train exposure led to a significant change of HR within 1 min of exposure onset (p=0.002), characterised by an initial and a delayed increase of HR. The high-vibration condition provoked an average increase of at least 3 bpm per train in 79% of the participants. Cardiac responses were in general higher in the high-vibration condition than in the low-vibration condition (p=0.006). No significant effect of noise sensitivity and gender was revealed, although there was a tendency for men to exhibit stronger HR acceleration than women.

CONCLUSIONS

Freight trains provoke HR accelerations during sleep, and the vibration characteristics of the trains are of special importance. In the long term, this may affect cardiovascular functioning of persons living close to railways.

Living alongside railway tracks: Long-term effects of nocturnal noise on sleep and cardiovascular reactivity as a function of age

Very few studies were devoted to permanent effects of nocturnal railway noise on sleep and cardiovascular reactivity. We investigated the effects of nocturnal railway noise on sleep and cardiovascular response in young and middle-aged adults living for many years either near a railway track or in a quiet area. Forty subjects (50% males) divided into two age groups (juniors: 26.2+/-3.6 and seniors: 56.2+/-4.2) participated in this experiment. Half of them lived near a railway track (RW group: 2.6 to 19 years) and the other half in a quiet environment (QE group: 8.1 to 14.2 years). After an adaptation night, all subjects underwent two nights in the laboratory: one control night and one noisy night (30 by-passes of a freight train). Sleep and cardiovascular modifications were assessed in response to noise. Sleep fragmentation indices were lower in RW subjects compared to QE whatever their age. In response to noise, there was a higher cardiovascular response rate to noise in RW juniors and a lower cardiovascular response rate in RW seniors compared to their age-paired QE counterparts. In conclusion, permanent exposure to nocturnal railway noise leads to decreased sleep fragmentation and to cardiovascular habituation. It is suggested that during the initial period experienced by residents living near railway tracks, nocturnal railway noise could induce a sensitization process on the autonomic response to noise reflecting a startle/defense reflex due to its functional significance, which progressively turns to habituation in the long-term if no adverse effect is experienced.

Arousal thresholds during human tonic and phasic REM sleep

The goal of the present study was to investigate arousal thresholds (ATs) in tonic and phasic episodes of rapid eye movement (REM) sleep, and to compare the frequency spectrum of these sub-states of REM to non-REM (NREM) stages of sleep. We found the two REM stages to differ with regard to behavioural responses to external acoustic stimuli. The AT in tonic REM was indifferent from that in sleep stage 2, and ATs in phasic REM were similar to those in slow-wave sleep (stage 4). NREM and REM stages of similar behavioural thresholds were distinctly different with regard to their frequency pattern. These data provide further evidence that REM sleep should not be regarded a uniform state. Regarding electroencephalogram frequency spectra, we found that the two REM stages were more similar to each other than to NREM stages with similar responsivity. Ocular activity such as ponto-geniculo-occipital-like waves and microsaccades are discussed as likely modulators of behavioural responsiveness and cortical processing of auditory information in the two REM sub-states.

Cardiovascular responses to railway noise during sleep in young and middle-aged adults

The aim of this study was to investigate the effects of nocturnal railway noise on cardiovascular reactivity in young (25.8 +/- 2.6 years) and middle-aged (52.2 +/- 2.5 years) adults during sleep. Thirty-eight subjects slept three nights in the laboratory at 1-week interval. They were exposed to 48 randomized pass-bys of Freight, Passenger and Automotive trains either at an 8-h equivalent sound level of 40 dBA (Moderate) and 50 dBA (High) or at a silent Control night. Heart rate response (HRR), heart response amplitude (HRA), heart response latency (HRL) and finger pulse response (FPR), finger pulse amplitude (FPA) and finger pulse latency (FPL) were recorded to measure cardiovascular reactivity after each noise onset and for time-matched pseudo-noises in the control condition. Results show that Freight trains produced the highest cardiac response (increased HRR, HRA and HRL) compared to Passenger and Automotive. But the vascular response was similar whatever the type of train. Juniors exhibited an increased HRR and HRA as compared to seniors, but there was no age difference on vasoconstriction, except a shorter FPL in seniors. Noise level produced dose-dependent effects on all the cardiovascular indices. Sleep stage at noise occurrence was ineffective for cardiac response, but FPA was reduced when noise occurred during REM sleep. In conclusion, our study is in favor of an important impact of nocturnal railway noise on the cardiovascular system of sleeping subjects. In the limit of the samples studied, Freight trains are the most harmful, probably more because of their special length (duration) than because of their speed (rise time).

Modeling the impact of impulsive stimuli on sleep-wake dynamics

A neuronal population model of the sleep-wake switch is extended to incorporate impulsive external stimuli. The model includes the mutual inhibition of the sleep-active neurons in the hypothalamic ventrolateral preoptic area (VLPO) and the wake-active monoaminergic brainstem populations (MA), as well as circadian and homeostatic drives. Arbitrary stimuli are described in terms of their relative effects on the VLPO and MA nuclei and represent perturbations on the normal sleep-wake dynamics. By separating the model's intrinsic time scales, an analytic characterization of the dynamics in a reduced model space is developed. Using this representation, the model's response to stimuli is studied, including the latency to return to wake or sleep, or to elicit a transition between the two states. Since sensory stimuli are known to excite the MA, we correspondingly investigate the model's response to auditory tones during sleep, as in clinical sleep fragmentation studies. The arousal threshold is found to vary approximately linearly with the model's total sleep drive, which includes circadian and homeostatic components. This relationship is used to reproduce the clinically observed variation of the arousal threshold across the night, which rises to a maximum near the middle of the night and decreases thereafter. In a further application of the model, time-of-night arousal threshold and body temperature variations in an experimental sleep fragmentation study are replicated. It is proposed that the shift of the extrema of these curves to a greater magnitude later in the night is due to the homeostatic impact of the frequent nocturnal disturbances. By modeling the underlying neuronal interactions, the methods presented here allow the prediction of arousal state responses to external stimuli. This methodology is fundamentally different to previous approaches that model the clinical data within a phenomenological framework. As a result, a broader understanding of how impulsive external stimuli modulate arousal is gained.

Functions of Sleep Architecture and the Concept of Protective Fields

This article focuses on the function of human sleep architecture and, where it adjoins, on the ultradian rhythm of NREM and REM cycles. In healthy adult human sleep, NREM and REM sleep succeed each other in 90-110 min intervals. This ultradian pattern of NREM/REM succession is cyclical. Sleep architecture relates to the shifting between sleep stages of varying sleep intensity and arousal thresholds. It has been found to follow a typical but non-cyclical pattern throughout the night. In the first third of the night, light sleep alternates predominantly with slow wave sleep (SWS). As sleep progresses, the amount of SWS typically decreases and REM sleep increases. In the last third of the night, light sleep almost exclusively alternates with REM sleep. The author postulates that one function of the non-cyclical succession of sleep stages is the erection and maintenance of a protective field around the sleeper. A protective field is to be understood as an area of relative safety, minimizing the chances for an intruder to enter the field without detection. The frequent shifts between sleep phases with low and high arousal thresholds allow a periodic screening of the sleep environment for danger signals. The relevant literature on sleep architecture, ultradian rhythms and its determinants is reviewed and the implications of the concept of protective fields are discussed.

Psychological approaches to the prevention and inhibition of nocturnal epileptic seizures: a meta-analysis of 70 case studies

The major purpose of this study was to outline and differentiate diagnostic and therapeutic conditions for the usefulness of psychological approaches in controlling nocturnal epileptic seizures. Data on 70 patients (12 'own', 58 from other studies) were evaluated which suggest that at least one psychological approach was primarily responsible for improving nocturnal seizure control. Outcome-related comparisons were made for the behavioural state at seizure onset, seizure types, epilepsy syndromes, types of psychological approaches, age, gender, mental disability, duration of epilepsy, impact of psychological treatment on intake of antiepileptic medication, and additional occurrence of diurnal seizures. Seizure favouring or precipitating factors as well as types of seizures and epilepsies were analysed and compared with regard to therapeutic components and strategies. Respective data of patients with exclusively nocturnal seizures or with transitory shifts of seizure activity to the night were evaluated separately. Psychological approaches were effective in a broad range of indications, whose limitations regarding age, level of intelligence, seizure semiology, or type and duration of epilepsy cannot yet be determined. Therapeutic strategies may depend on the concomitant occurrence of diurnal seizures as well as on the identification, types and number of seizure favouring factors, the type and duration of initial symptoms, the behavioural state at seizure onset, the type of epilepsy, and the level of intelligence. Despite methodological reservations emerging from the designs, number, and comparability of the included studies, there is sufficient evidence that psychological approaches to the control of nocturnal seizures clearly deserve more consideration in research. Also, their carefully prepared and designed use in clinical practice should be encouraged.

Ontogenetic variations in auditory arousal threshold during sleep

Developmental variations in auditory arousal thresholds during sleep were investigated in four groups of normal male subjects--children, preadolescents, adolescents, and young adults. Arousal thresholds were determined during NREM and REM sleep for tones presented via earphone insert on a single night following two adaptation nights of undisturbed sleep. Age-related relationships were observed for both awakening frequency and stimulus intensity required to effect awakening, with awakenings occurring more frequently in response to lower stimulus intensities with increasing age. Although stimulus intensities required for awakening were high and statistically equivalent across sleep stages in nonadults, higher intensity stimuli were required in Stage 4 relative to Stage 2 and REM sleep in adults. These results confirm previous observations of marked resistance to awakening during sleep in preadolescent children and suggest that processes underlying awakening from sleep undergo systematic modification during ontogenetic development.

Cardiovascular effects of impulse noise, road traffic noise, and intermittent pink noise at LAeq = 75 dB, as a function of sex, age, and level of anxiety: a comparative study. II. Digital pulse level and blood pressure data

In a previous paper, in which the experimental conditions of the present research are fully described (Parrot et al., this issue), heart rate (HR) was studied in 60 male and in 60 female subjects in response to a pile-driver noise (P), a gunfire noise (G), a road traffic noise (T), and an intermittent pink noise (R), all noises being emitted at the same LAeq = 75 dB for 15 min. Digital pulse level (PL) responses were concomitantly surveyed by the use of pulse oximetry, allowing continuous arterial oxygen saturation (SaO2) readings. An index of pulse reactivity (PRI) could be calculated. Arterial blood pressure was measured 7 times from the beginning to the end of each trial. At rest, within the last minutes preceding each exposure to any of the 4 noises, no difference for conditions or for age in prestimulus PL was observed. In all cases, sex is a highly significant source of variation: Mean resting SaO2 values are higher in women than in men. Mean SaO2 at rest was also found to be significantly higher in anxious (Am) than in anxiety-free (Nm) men. When the noise was on for 15 min, increase in PL prevailed to be in most cases in men. In contrast, decrease or near-zero changes prevailed in 1 case out of 2 in the female subgroups. In all groups, the mean PRIs are significantly higher in men. In no case did the age factor prove to be a significant source of PRI variation.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular responses and electroencephalogram disturbances to intermittent noises: effects of nocturnal heat and daytime exposure

During sleep, in thermoneutral conditions, the noise of a passing vehicle induces a biphasic cardiac response, a transient peripheral vasoconstriction and sleep disturbances. The present study was performed to determine whether or not the physiological responses were modified in a hot environment or after daytime exposure to both heat and noise. Eight young men were exposed to a nocturnal thermoneutral (20 degrees C) or hot (35 degrees C) environment disturbed by traffic noise. During the night, the peak intensities were of 71 dB(A) for trucks, 67 dB(A) for motorbikes and 64 dB(A) for cars. The background noise level (pink noise) was set at 30 dB(A). The noises were randomly distributed at a rate of 9.h-1. Nights were equally preceded by daytime exposure to combined heat and noise or to no disturbance. During the day, the noises as well as the background noise levels were increased by 15 dB(A) and the rate was 48.h-1. Electroencephalogram (EEG) measures of sleep, electrocardiograms and finger pulse amplitudes were continuously recorded. Regardless of the day condition, when compared with undisturbed nights, the nocturnal increase in the level of heart rate induced by heat exposure disappeared when noise was added. Percentages, delays, magnitudes and costs of cardiac and vascular responses as well as EEG events such as transient activation phases (TAP) due to noise were not affected by nocturnal thermal load or by the preceding daytime exposure to disturbances.(ABSTRACT TRUNCATED AT 250 WORDS)

Motor responsiveness to stimuli presented during sleep: the influence of time-of-testing on sleep stage analyses

The relationship between time-of-night of testing (circadian factors) and motor responsiveness to stimuli presented during different stages of sleep was examined. Nine males slept for two nonconsecutive nights in the laboratory. On Night 1, tympanic temperature was assessed at 30 min intervals. On Night 2, responsiveness was assessed with an incremental series of tones presented in sleep stages 2, 3/4, and REM throughout the night. Subjects were instructed to make a microswitch closure to the tones. Results showed that for all stages, responsiveness decreased across thirds of the night. Because the distribution of each sleep stage differed across the night, the effects on responsiveness due to time-of-testing and to sleep stage were confounded. When time-of-testing was held constant, responsiveness was greater in stages 2 and REM than in stage 3/4. When time-of-testing was not held constant, effects nearly opposite of the latter could be demonstrated.

Temperature, time-of-night of testing, and responsiveness to stimuli presented while sleeping

The present study examined how time-of-night of testing and body temperature related to responsiveness to stimuli presented in sleep. Nine males slept for two nonconsecutive nights in the sleep laboratory. On Night 1, tympanic temperature was assessed at 30-min intervals. On Night 2, responsiveness was assessed with an incremental series of tones (5dB steps) presented in sleep stages 2, 3/4, and REM throughout the night (0030-0800 h). Subjects were instructed and given practice prior to sleep to make a microswitch closure to the tones. Results showed a curvilinear pattern of responsiveness across the night in that the intensity of tones required for a response increased until about 0530 h, then decreased thereafter. This pattern of responsiveness was positively related to the circadian rhythm of body temperature. A close correspondence was also found between the temperature trough and the performance trough (both occurred at about 0530 h). A greater emphasis on circadian factors may help understand previously reported but contradictory findings. The present results also suggest that measures of responsiveness follow a circadian pattern regardless of the sleep/wake state.

Sleep, brain activation and cognition

Some data have shown the presence of time-of-day effects in learning processes. We explore here whether the same phenomenon occurs during the night and how it relates to REM sleep. In an initial approach to the question, this paper points out the relationships between: 1) REM sleep and brain activation, and 2) REM sleep and information processing. The data are discussed in terms of a REM sleep implication on information processing and we examine the possibility of modifying this processing by acting on REM sleep.

Evoked K-complexes and cardiovascular responses to spindle-synchronous and spindle-asynchronous stimulus clicks during NREM sleep

The hypothesis that the functional role of the sleep spindle is to preserve sleep by inhibiting sensory input (Yamadori 1971) was examined. Series of 44 dB, 10 msec, 1000 c/sec 'clicks' were presented to 12 subjects at a 30-sec ISI during stage 2 sleep either during spindle bursts (i.e. spindle-synchronous clicks) or during interburst periods (i.e. spindle-asynchronous clicks). Contrary to the spindle inhibitory hypothesis, cortical EEG and cardiovascular responses showed no evidence of spindle 'suppression'. Evoked K-complexes were potentiated by the spindle-synchronous stimulation. A second study with 7 subjects replicated this result and extended the finding to include stage 3--4 sleep. It was suggested that the potentiation of evoked K-complexes was due to phasic reductions in inhibitory action during sleep spindles resulting in increased transmission of sensory events or, perhaps, an increase in the lability of certain EEG response systems.

Effect of flurazepam on sleep spindles and K-complexes

In this research, a quantitative study of the EEG from 5 subjects permitted a detailed analysis of the effect of 30 mg of flurazepam administered over 7 nights. Four placebo baseline nights and 3 placebo withdrawal nights were also recorded. For 4 of the subjects, a nondrug and nonplacebo follow-up record was obtained 4 to 6 weeks later. The subjects were 4 females, 1 male, age range 23-42. All complained of either sleep onset greater than 45 min, sleep length of less than 6 h, or two or more sleep awakenings. Compressed spectral analysis yielded a computer-generated somnogram on each of the 15 nights of sleep, and an automated spindle detector was used to count and measure the duration of spindle bursts with frequencies of 12.25-15.5 c/sec on baseline nights 3 and 4, drug nights 1, 2, 3 and 7, on the 3rd withdrawal night, and on the 4-6 week followup record. K-complexes were scored visually on the 4th baseline and 7th drug nights. There were no significant differences in spindle rate per minute among baseline nights and the follow-up record. By the 2nd drug night, spindle rate had significantly increased over the baseline rate. Linear contrast analysis indicated there was a significant increase of spindle rate over drug nights. All 5 subjects showed this pattern of increase. In contrast to the increase in spindle activity, the rate per minute of K-complexes significantly decreased during drug administration.