Reduced cerebral blood flow and white matter hyperintensities predict poor sleep in heart failure

Internal carotid artery blood flow and pulsatility index in cognitively impaired people with chronic heart failure

AIMS

Mild cognitive impairment and dementia are common and serious co-morbidities in people with chronic heart failure (HF) as they increase hospitalization rates, mortality and health care costs. Upon other factors, dysregulated cerebral perfusion might contribute to brain pathology. We aimed to evaluate the association of non-invasively measured blood flow (BF) and pulsatility index (PI) of the internal carotid artery (ICA) with (i) chronic HF parameters, (ii) brain morphologic measures and (iii) cognitive impairment.

METHODS AND RESULTS

This post-hoc analysis of the observational, prospective Cognition.Matters-HF study included 107 chronic HF patients without atrial fibrillation or carotid artery stenosis (aged 63 ± 10 years; 19% women). Using extracranial sonography, we measured ICA-BF and ICA-PI 1.5 cm distal of the carotid bifurcation. Brain magnetic resonance imaging was performed on a 3-Tesla scanner to quantify cerebral atrophy, hippocampal atrophy and white matter hyperintensities. Extensive neuropsychological testing tested the cognitive domains intensity of attention, visual/verbal memory and executive function (including its subdomains selectivity of attention, visual/verbal fluency and working memory) using a comprehensive test battery. (i) Neither ICA-BF (median 630 (quartiles 570, 700) mL/min) nor ICA-PI (1.05 (0.96. 1.23)) related to left ventricular ejection fraction, left atrial volume index or NT-proBNP. (ii) Higher ICA-PI (r = 0.25; P = 0.011), but not ICA-BF (r = 0.08; P = 0.409), associated with increased volume of white matter hyperintensities beyond ageing, while neither ICA-PI nor ICA-BF related to cerebral or hippocampal atrophy indices. (iii) ICA-BF, but not ICA-PI, positively correlated with age-adjusted T-scores of executive function (r = 0.38; P < 0.001) and its subdomains working memory (r = 0.32; P < 0.001) and visual/verbal fluency (r = 0.32; P < 0.001). In a multivariate linear model of executive function, only ICA-BF (T = 3.79; P < 0.001), but not HF or magnetic resonance imaging parameters, remained a significant correlate of executive function.

CONCLUSIONS

ICA-BF and ICA-PI, measured in broadly available extracranial sonography, independently related to measures of functional and structural brain changes in people with chronic HF, respectively. Due to limitations of this cross-sectional approach without a healthy control group, larger controlled longitudinal studies are needed to further elucidate the role of ICA-BF dysregulation and its implication for clinical care in this vulnerable cohort.

Preliminary cross-sectional investigations into the human glymphatic system using multiple novel non-contrast MRI methods

We discuss two potential non-invasive MRI methods to cross-sectionally study two distinct facets of the glymphatic system and its association with sleep and aging. We apply diffusion-based intravoxel incoherent motion (IVIM) imaging to evaluate pseudodiffusion coefficient, D * , or cerebrospinal fluid (CSF) movement across large spaces like the subarachnoid space (SAS). We also performed perfusion-based multi-echo, Hadamard encoded multi-delay arterial spin labeling (ASL) to evaluate whole brain cortical cerebral blood flow (CBF) and transendothelial exchange (Tex) of water from the vasculature into the perivascular space and parenchyma. Both methods were used in young adults (N=9, 6F, 23±3 years old) in the setting of sleep and sleep deprivation. To study aging, 10 older adults, (6F, 67±3 years old) were imaged after a night of normal sleep only and compared with the young adults. D * in SAS was significantly (p<0.05) lesser after sleep deprivation (0.014±0.001 mm2/s) than after normal sleep (0.016±0.001 mm2/s), but was unchanged with aging. Cortical CBF and Tex on the other hand, were unchanged after sleep deprivation but were significantly lower in older adults (37±3 ml/100g/min, 476±66 ms) than young adults (42±2 ml/100g/min, 624±66 ms). IVIM was thus, sensitive to sleep physiology and multi-echo, multi-delay ASL was sensitive to aging.

Sleep Quality and Cognitive Decline Across the Adult Age Range: Findings from the Maastricht Aging Study (MAAS)

BACKGROUND

Sleep disturbances have been linked with cognitive decline and a higher risk of dementia. However, there is a lack of studies with sufficient follow-up duration, a detailed neuropsychological assessment and adequate control of main confounders.

OBJECTIVE

To investigate the relation between self-reported sleep quality and cognitive decline over 12 years in cognitively healthy individuals from the general population.

METHODS

We used data from the Maastricht Aging Study (MAAS), a Dutch population-based prospective cohort study of 1,823 community-dwelling adults aged 24 to 82 years at baseline. Cognitive performance was measured at baseline, 6 and 12 years on verbal memory, executive functions, and information processing speed. Sleep quality was assessed at baseline using the sleep subscale score of the 90-item Symptom Checklist (SCL-90). Additional modifiable dementia risk factors were summarized in the LIfestyle for BRAin health (LIBRA) risk score. Weighted linear mixed models tested the association between continuous scores and tertiles of subjective sleep quality and change in cognitive performances over time. Models were adjusted for age, gender, educational level, LIBRA, and use of hypnotic (sleep) medication.

RESULTS

Worse sleep quality was associated with faster decline in processing speed. At older age (≥65 years), it was also associated with faster decline in verbal memory. Association were independent of other modifiable dementia risk factors and use of hypnotic medication. Directionally similar but non-significant associations were found between worse sleep quality and executive functions.

CONCLUSIONS

In this population-based study across the adult age range, poor self-reported sleep was associated with accelerated cognitive decline.

Dimensions of sleep characteristics and predictors of sleep quality among heart failure patients: A STROBE compliant cross-sectional study in Jordan

Awareness of poor sleep quality and sleep disturbances, as some of the factors that affect negatively quality of life for patients with the different classes of heart failure (HF) would enable health care providers to offer more comprehensive care. The purposes of this study were to describe sleep quality and predictors of disturbances in sleep in heart failure patients in Jordan. An explanatory cross- sectional design was employed to examine sleep quality, dimensions of sleep characteristics, types of disturbances in sleep within the different classes of HF in Jordan. Data were collected from 2 cardiac clinics and 2 medical clinics at 3 hospitals in Jordan. The most common types of disturbances in sleep in all classes of HF were waking up for urination, waking in the middle of the night or early morning, waking up due to cough and snoring, and difficulty to fall asleep within the 30 minutes. However, waking up due to feeling cold or hot were rarely reported in all classes of patients with HF. Regression analysis revealed that significant correlations were found between sleep quality and gender, disease duration, number of medications currently taken and ejection fraction (P < .05). Our findings indicated that sleep quality and disturbances in sleep were worsening with the increase of the New York heart association functional classification sheet class. Moreover, sleep quality had a significant association with gender, disease duration, ejection fraction, and the number of medications currently taken.

Sleep quality among different classes of heart failure patients in Jordan: A STROBE compliant cross-sectional study

Many researchers emphasize the importance of studying sleep quality among patients with heart failure (HF). Because of the importance of this topic, many studies have been conducted to address the different aspects of sleep-in various populations of patients with HF. The purposes of our study were: to assess the types of disturbances in sleep within the different classes of HF, and to assess whether there were differences in the levels of sleep quality and types of disturbances in sleep within the different classes in non-hospitalized Jordan patients with HF. Data were gathered from 2 cardiac clinics and 2 medical clinics at 3 Jordan hospitals. A minimum sample of 200 people was recruited to participate in this study based on these criteria and factors. The prevalence of low sleep quality and types of disturbances in sleep were increased with the increase in New York Heart Association class. Nearly 3 quarters of the study sample had poor sleep quality 73.5% (n = 147). Using a score of 5 as a cut point, 147 patients with HF in our study sample had poor sleep quality. The most common types in all classes were waking up for urination, waking in the middle of the night or early morning, waking up due to coughing and snoring, and difficulty falling asleep within 30 minutes. However, waking up due to feeling cold or hot were rarely reported in all classes of patients with HF. Poor sleep quality negatively affects the quality of life in patients with HF by decreasing physical cognitive and psychosocial performance in those patients. This is the first study in literature study sleep quality in the different New York Heart Association functional classes.

Laterality of Posterior Cerebral Artery and White Matter Hyperintensities in Patients with Severe Internal Carotid Artery Stenosis

BACKGROUND

Collateral status of the circle of Willis was associated with white matter hyperintensities (WMHs) in patients with internal carotid artery (ICA) stenosis, but few have investigated the effect of leptomeningeal anastomoses.

OBJECTIVE

The aim of this study was to observe the association between WMHs and the laterality of the posterior cerebral artery (PCA) that presents leptomeningeal anastomoses in patients with severe ICA stenosis.

MATERIALS AND METHODS

WMHs and ipsilateral PCA laterality were evaluated in patients with unilateral ICA stenosis ≥70% (including occlusion) and contralateral ICA stenosis <50% or no stenosis. Ipsilateral PCA laterality was compared between two groups of no/mild and severe score of global, deep and periventricular WMHs, respectively.

RESULTS

We included 115 patients with unilateral ICA stenosis ≥70%. There were 60 patients with no/mild and 55 with severe global WMHs. The patients with severe global WMHs were older (OR = 1.849, 95% CI: 1.058-3.229, P = 0.031) and had higher incidence of negative PCA laterality (OR = 3.301, 95% CI: 1.140-9.558, P = 0.028). The patients with severe deep WMHs were also older (OR = 2.031, 95% CI: 1.130-3.651, P = 0.018) and had higher incidence of negative PCA laterality (OR = 4.250, 95% CI: 1.501-12.032, P = 0.006). There was no significant difference between the patients with no/mild and severe periventricular WMHs in the incidence of negative PCA laterality.

CONCLUSIONS

The incidence of negative PCA laterality was higher in patients with severe global and deep WMHs, but not higher in patients with severe periventricular WMHs. The leptomeningeal anastomoses may affect the deep WMHs in patients with severe ICA stenosis.

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.

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.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

The central nervous system and heart failure

The view that chronic heart failure was exclusively a disease of the heart dominated the cardiovascular literature until relatively recently. However, over the last 40 years it has increasingly come to be seen as a multisystem disease. Aside from changes in the sympathetic and parasympathetic nervous systems and the renin-angiotensin-aldosterone system, adaptations to the lungs, muscles and gastrointestinal tract have been clearly documented. It is clear that the brain and CNS are also affected in patients with heart failure, although this is often under recognized. The purpose of this review is to summarize the changes in the structure and biochemical function of the CNS in patients with chronic heart failure and to discuss their potential importance.

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 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.

Multimodal brain imaging investigation of self-reported sleep quality and daytime sleepiness in older adults with heart failure

PURPOSE OF THE STUDY

Individuals with heart failure (HF) have a high frequency of sleep problems. Patients with HF present with structural brain changes different from normal aging including reductions in brain volume, increases in white matter hyperintensity (WMH) and reduced cerebral blood flow. These structural changes in the brain may explain the pathophysiology of sleep and daytime problems. The objective of this study was to determine whether multimodal imaging data are related to self-reported sleep problems and daytime sleepiness in older adults with HF.

METHODS

Participants in this study underwent magnetic resonance imaging scans on the General Electric 3.0 T Discovery MR750 to acquire WMH, cerebral blood flow and brain volume. Data on 37 stable HF patients (mean age = 68; SD = 5.75) were included.

RESULTS

In this sample, WMH was associated with daytime sleepiness (p = 0.025). However, gray and white matter volume and cerebral blood flow were not associated with daytime sleepiness, sleep quality or insomnia.

CONCLUSION

Although further studies are needed to determine the relationship between WMH and sleep and daytime problems, the findings preliminarily support that increases in WMH from ischemic changes could explain increases in daytime sleepiness among people with HF.

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.

The Relationship Between Apolipoprotein ε4 Carrier Status and Sleep Characteristics in Cognitively Normal Older Adults

The apolipoprotein (APOE) ε4 allele, a well-described genetic risk factor for late-onset Alzheimer disease (AD), is associated with sleep disturbances even in cognitively normal older adults, although it is not clear whether this association is independent of sleep apnea. We sought to extend previous studies by examining whether cognitively normal older adults without self-reported sleep apnea who carry the APOE ε4 allele have altered sleep characteristics compared to noncarriers. Data from N = 36 (APOE ε4 carriers [n = 9], noncarriers [n = 27]) cognitively normal older adults (Clinical Dementia Rating [CDR] scale = 0) without self-reported sleep apnea were used for these analyses. Participants wore an actigraph for 7 days to determine sleep characteristics. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to assess sleep quality and daytime sleepiness, respectively. The APOE ε4 carriers had a higher number of awakenings compared to the noncarriers ( P = .02). There was no significant difference in the PSQI global score and the ESS; however, the PSQI subcomponent of daily disturbances was significantly higher in APOE ε4 carriers ( P = .03), indicating increased daytime dysfunction is related to disrupted sleep. This study provides evidence that individuals who are cognitively normal and genetically at risk of AD may have disrupted sleep. These findings are consistent with prior studies and suggest that sleep disruption may be present in the presymptomatic stages of AD.

Apolipoprotein E ε4: A Possible Risk Factor of Intracranial Pressure and White Matter Perfusion in Good-Grade Aneurysmal Subarachnoid Hemorrhage Patients at Early Stage

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and complicated disease with significant morbidity and mortality. Previous studies have shown that genetic susceptibility may play an important role in the outcome of a given individual with aSAH. This study evaluates the potential association in effects of the APOE allele on the early brain injury (EBI) in light of elevated intracranial pressure (ICP) and cerebral perfusion disorders in a consecutive series of non-comatose Chinese patients with aSAH. A total of 122 patients with aSAH (54 males and 68 females) were enrolled in this study. Demographic and clinical data were collected. We measured ICP before microsurgical clipping or endovascular coiling during the first 72 h after aneurysm rupture. Computed tomography perfusion (CTP) examination in patients was performed before treatment. The distributions of APOE genotypes and alleles matched Hardy–Weinberg law (p > 0.05). In this study, 68 patients (55.7%) had a normal ICP, whereas 54 (44.3%) had an elevated ICP. Fourteen of 21 patients with APOE ε4 had an elevated ICP, which was significantly different from those without APOE ε4 (p = 0.03). The patients with the ε4 allele had a higher incidence of elevated ICP [p = 0.009, 95% confidence interval (CI) = 1.481–15.432, odds ratio = 4.780] than those without this allele. For CTP measurements, a lower mean cerebral blood flow (difference, −4.74; 95% CI, 0.53–8.94 s, p = 0.03), longer mean transit time (difference, 0.47; 95% CI, −0.87 to −0.78, p = 0.02), and time-to-peak (difference, 2.29; 95% CI, −3.64 to −0.93 s, p = 0.02) were observed in patients with ε4 allele than in those without in the internal capsule regions. In conclusion, the APOE ε4 allele predisposes patients to elevated ICP and perfusion disorders in white matter regions during the first 72 h after aSAH. The presence of an APOE ε4 allele plays an important role in the EBI response to aSAH.

Inhibition of Blood-Brain Barrier Disruption by an Apolipoprotein E-Mimetic Peptide Ameliorates Early Brain Injury in Experimental Subarachnoid Hemorrhage

Apolipoprotein E (ApoE)-mimetic peptides have been demonstrated to be beneficial in secondary brain injury following experimental subarachnoid hemorrhage (SAH). However, the molecular mechanisms underlying these benefits in SAH models have not been clearly identified. This study investigated whether an ApoE-mimetic peptide affords neuroprotection in early brain injury (EBI) following SAH by attenuating BBB disruption. SAH was induced by an endovascular perforation in young, healthy, male wild-type (WT) C57BL/6J mice. Multiple techniques, including MRI with T2-weighted imaging, ¹⁸ FDG PET-CT scanning and histological studies, were used to examine BBB integrity and neurological dysfunction in EBI following SAH. We found that SAH induced a significant increase of BBB permeability and neuron apoptosis, whereas ApoE-mimetic peptide treatment significantly reduced the degradation of tight junction proteins and endothelial cell apoptosis. These effects reduced brain edema and neuron apoptosis, increased cerebral glucose uptake, and improved neurological functions. Further investigation revealed that the ApoE-mimetic peptide inhibited the proinflammatory activators of MMP-9, including CypA, NF-κB, IL-6, TNF-α, and IL-1β, thereby ameliorating BBB disruption at the acute stage of SAH. Together, these data indicate that ApoE-mimetic peptide may be a novel and promising therapeutic strategy for EBI amelioration after SAH that are worthy of further study.

PROspective MEmory Training to improve HEart failUre Self-care (PROMETHEUS): study protocol for a randomised controlled trial

Background

Cognitive impairment is seen in up to three quarters of heart failure (HF) patients and has a significant negative impact on patients’ health outcomes. Prospective memory, which is defined as memory to carry out future intentions, is important for functional independence in older adults and involves application of multiple cognitive processes that are often impaired in HF patients. The objective of this study is to examine the effects of prospective memory training on patients’ engagement in HF self-care and health outcomes, carer strain and quality of life.

Methods/design

The proposed study is a randomised, controlled trial in which 200 patients diagnosed with HF, and their carers will be recruited from 3 major hospitals across Melbourne. Eligible patients with HF will be randomised to receive either: 1) The Virtual Week Training Program - a computerised prospective memory (PM) training program (intervention) or 2) non-adaptive computer-based word puzzles (active control). HF patients’ baseline cognitive function will be compared to a healthy control group (n = 60) living independently in the community. Patients will undergo a comprehensive assessment of PM, neuropsychological functioning, self-care, physical, and emotional functioning. Assessments will take place at baseline, 4 weeks and 12 months following intervention. Carers will complete measures assessing quality of life, strain, perceived control in the management of the patients’ HF symptoms, and ratings of the patients’ level of engagement in HF self-care behaviours.

Discussion

If the Virtual Week Training Program is effective in improving: 1) prospective memory; 2) self-care behaviours, and 3) wellbeing in HF patients, this study will enhance our understanding of impaired cognitive processes in HF and potentially is a mechanism to reduce healthcare costs.

Trial registration

Australian New Zealand Clinical Trials Registry #366376; 27 May 2014. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366376&isClinicalTrial=False.

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

BACKGROUND/OBJECTIVES

Evidence of a relationship between non-breathing-related sleep symptoms and silent markers of cerebral small vessel disease (SVD) is scarce. The present study aimed to evaluate this association in older people living in rural Ecuador, where the burden of stroke is on the rise.

METHODS

A group of Atahualpa residents, aged ≥60 years, were interviewed with a validated Spanish version of the Pittsburgh Sleep Quality Index, and underwent magnetic resonance imaging (MRI) for identification of silent markers of SVD. Using multinomial logistic regression analysis, after adjusting for demographics and cardiovascular health status, it was evaluated whether sleep quality is associated with the severity of white matter hyperintensity (WMH), lacunar infarcts, and deep microbleeds.

RESULTS

Out of 311 people aged ≥60 years, 237 (76%) were enrolled into the study. Mean age was 70 ± 8 years, 59% were women, 83% had primary school education only, and 73% had a poor cardiovascular health status. Seventy-eight (33%) had poor sleep quality. The MRI showed: WMH in 154 (65%) participants (moderate-to-severe in 52); silent lacunar infarcts in 28 (12%); and deep microbleeds in 17 (7%). Poor sleep quality was associated with WMH presence (OR 2.44, 95% CI 1.26 to 4.71, p = 0.008) and severity (β coefficient 0.77, SE 0.37, p = 0.037), but not with silent lacunar infarcts or deep microbleeds.

CONCLUSIONS

The present study showed an association between poor sleep quality and WMH severity. Further longitudinal studies would help to elucidate the cause and effect of this relationship.