Abstract WP75: Association Between Sleep-disordered Breathing And Post-stroke Fatigue

Background: Post-stroke fatigue (PSF) is a common and often disabling symptom, the etiology of which is poorly understood. Sleep-disordered breathing (SDB) is also highly prevalent among stroke survivors. We explored the relationship between SDB and PSF over time in a bi-ethnic cohort.

Methods: Ischemic stroke (IS) patients within the Brain Attack Surveillance in Corpus Christi (BASIC) project were identified through active and passive surveillance, and were offered home SDB screening with a well-validated cardiopulmonary sleep apnea testing device, the ApneaLink Plus. The primary exposure was the respiratory event index (REI). The primary outcome was PSF as measured by the SF-36 vitality scale (lower scores reflect greater fatigue). SDB and PSF were measured at baseline, 3, 6, and 12 months post-stroke. A linear regression model, using GEE to account for repeated measures, was used to examine the associations between REI and PSF at each time point adjusting for sociodemographics, stroke severity, depressive symptoms, pre-stroke fatigue, and comorbidities.

Results: SDB screening and at least one PSF assessment were completed by 462 IS patients, who were 44% female, 61% Mexican American (MA), 26% non-Hispanic white, 7% Black, and 5% other race/ethnicity. Median NIHSS was 2 (IQR: 1-4). Multivariable regression model results are presented in the Table. Higher REI at 3 months was associated with greater PSF at 3 months (β= -1.87, 95%CI -3.47, -0.27), but there was no association between REI and PSF at 6 or 12 months. Across timepoints, female sex, depressive symptoms at time of assessment, pre-stroke medication for depression, higher levels of pre-stroke fatigue, and vascular risk factor burden were associated with greater PSF, whereas MA ethnicity was associated with less PSF.

Conclusions: Higher REI was associated with greater PSF in the early post-stroke period, but no association was observed at 6 months and beyond. MA ethnicity seems to be protective against PSF.

Abstract TMP108: Improvements In Sleep Apnea Are Associated With Improvements In NIHSS In The First Year After Stroke

Introduction: Sleep apnea, a very common condition among post-stroke patients, is associated with worse functional, cognitive, and neurological outcomes after stroke. Little is known about the association between change of sleep apnea and changes in outcome over time.

Methods: Associated with the Brain Attack Surveillance in Corpus Christi (BASIC) project, ischemic stroke patients (2016-2019) were offered sleep apnea testing with a portable respiratory monitor (ApneaLink Plus) shortly after stroke and at 3, 6, and 12 months post-stroke. Sleep apnea was quantified using the respiratory event index (REI), the number of apneas plus hypopneas per recording hour. At 3, 6, and 12-months post-stroke, functional outcome was assessed using activities of daily living (ADL)/instrumental activities of daily living (IADL) score (1-4, lower better); cognitive outcome was assessed using the Modified Mini-Mental State Examination (3MS) (0-100, higher better); neurological outcome was assessed using the NIHSS (0-42, lower better). Multivariate mixed models were fitted under a Bayesian approach to obtain random slopes in REI over time and the three outcomes (1-unit change in outcome per month), adjusted for age, sex, ethnicity, pre-stroke function and cognitive status, education, marital status, stroke history, tpa use, recurrent stroke, and depression. Linear regression models assessed the association between random slope of REI and random slopes of the three outcomes.

Results: Of the 482 Mexican American or non-Hispanic white participants with at least one REI measurement, in fully adjusted models, improvement in sleep apnea was significantly associated with improvement in NIHSS (0.0094 (95% CI: 0.0070, 0.0118)) but not with changes in ADL/IADL or 3MS.

Conclusions: Improvement in sleep apnea paralleled improvement in neurological status over the first year after stroke.

0531 Characterization of Sleep-Disordered Breathing among Newborn Infants with Myelomeningocele

Introduction

Myelomeningocele (MMC) is a neural tube defect associated with hindbrain herniation (Chiari II malformation) and respiratory center dysfunction. Prior cross-sectional polysomnographic studies indicated that older children with MMC have an elevated risk of sleep-disordered breathing (SDB), a risk factor for sudden death. Most infants with MMC (78%) had abnormal pneumograms, reported predominantly as central sleep apnea (CSA) and sleep-related hypoventilation (SRH). Pneumograms, however, have significant limitations compared with full polysomnography (PSG).

Methods

The North-American Fetal Therapy Network (NAFTNet) with nine participating sites has collaborated in a prospective study of SDB among infants with MMC. Bedside PSGs were conducted among infants >35 weeks post-menstrual age without supplemental oxygen or respiratory support. PSGs were scored by a pediatric-experienced RPSGT using the American Academy of Sleep Medicine infant sleep staging and pediatric scoring criteria for respiratory events. PSGs were reviewed independently by two board-certified pediatric sleep faculty who then reached diagnostic consensus.

Results

Twenty-eight PSGs were evaluated as an interim analysis from 4 of 9 participating sites. Many (11/28, 39.3%) infants had predominantly frequent hypopneas, which could not be distinguished confidently as central vs. obstructive by two experienced pediatric physicians. The proportions of neonates with CSA (3/28, 10.7%), OSA (6/28, 21.4%) and SRH (1/28, 3.6%) were small by comparison. Only 10/28 infants (35.7%) did not display significant SDB and 14/28 had PSG abnormalities considered clinically concerning. Across all subjects the median [IQR] hypopnea index was 18 [10, 33], central apnea index was 4 [1,7]) and obstructive apnea index was 1.0 [0, 6]. The median [IQR] apnea-hypopnea index was 28 [15, 46].

Conclusion

This ongoing study already provides the largest available cohort of neonates with MMC and PSG data. Predominant hypopneas were far more common than any other classified expression of SDB and were challenging to distinguish as central or obstructive. These data confirm the high frequency of SDB in MMC (64%), suggest that PSG may be an important consideration in neonates with MMC, but highlight that current scoring criteria may not always allow confident separation of central from obstructive SDB processes.

Support (If Any)

National Institutes of Health 1 R01 HL147261-01A1

0201 Sleep duration and timing is prospectively linked with increases in insulin resistance over late adolescence

Introduction

During puberty, adolescents experience a period of transient insulin resistance (IR) that normalizes upon full maturation. Yet, IR continues to rise for some adolescents, increasing metabolic disease and type 2 diabetes risk in adulthood. Whether short sleep duration and/or later sleep timing are risk factors for persistently increasing IR in late adolescence has not been explored.

Methods

The study population includes 362 adolescents from Mexico City enrolled in a longitudinal birth cohort (ELEMENT study). Beginning in 2015, when participants were between the ages of 9 and 17, there were 2 clinic visits that occurred approximately 2 years apart. During the visit, a fasting blood sample and anthropometric measurements were taken. Insulin resistance was assessed with glucose and insulin via HOMA-IR. Four groups were defined using puberty-specific cutpoints for IR: normal HOMA-IR over the follow-up period (reference), transition from normal to IR, transition from IR to normal, and IR at both time points. Baseline sleep assessments (sleep duration, timing, and variability of both duration and timing) were measured with 7-day actigraphy. Multinomial logistic regression models were used to evaluate associations between sleep duration and timing with HOMA-IR categories, adjusting for age, sex, and baseline pubertal status

Results

Seventeen percent of the sample developed insulin resistance over the follow-up period. Adolescents ≥1 hour below the sleep duration recommendations-for-age were over twice as likely to be in the group that developed IR compared to the normal group (95% CI 1.1, .9; P for trend=0.03). Similarly, adolescents who had a sleep midpoint later than 4:36 AM were 2.77 times as likely to be in the increasing HOMA-IR category (95% CI 1.0, 7.5; P for trend=0.05). Interestingly, there was no evidence that changes in adiposity over follow-up mediated associations between sleep and insulin resistance.

Conclusion

Insufficient sleep duration and late sleep timing were independently associated with development of IR over a 2-year period in peri-puberty. Adequate sleep during the pubertal period may promote metabolic health into young adulthood, independent of any changes in adiposity.

Support (If Any)

Dr. Jansen is supported by K01HL151673. The study is supported by P01 ES02284401.

0305 Irregularities in Sleep Duration and Biomarkers of Cardiovascular Disease across the Menstrual Cycle

Introduction

Irregular sleep duration may disrupt circadian rhythms necessary for optimal cardiovascular function. Yet, few studies have examined irregular sleep duration in relation to cardiovascular health, particularly among diverse cohorts of reproductive-age women. This study examined associations between sleep duration irregularities across the menstrual cycle and cardiovascular disease biomarkers in a cohort of healthy, premenopausal women.

Methods

We utilized the BioCycle micro-longitudinal cohort study of 259 regularly menstruating women aged 18–44 years. This measurement-intense study collected cardiovascular disease biomarkers at key reproductive time-points along the menstrual cycle (approximately days 2,7,12,13,14,18,22,27 of a 28-day cycle) across two cycles. Specifically, we assessed serum high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol, triglycerides, and C-reactive protein (CRP). Women recorded sleep duration in daily diaries concurrently. We computed a system of four mathematical measures, the L-moments, robust versions of location, dispersion, skewness, and kurtosis for series of recorded sleep durations. Using linear mixed models with random intercepts and inverse probability weighting we estimated associations between irregular sleep duration and cardiovascular disease biomarkers in all women and within a subset of non-white women. Adjusted analysis accounted for baseline characteristics and time-varying hormonal changes across the menstrual cycle.

Results

Woman-specific mean sleep duration ranged from 4.4 to 10.6 hours. A one-hour increase in dispersion of sleep duration was associated with a lower mean LDL and higher mean HDL for non-white women (-19.4%, 95%CI -30.9,-6.0% and 24.7%, 95%CI 8.2,43.0, respectively). Unbalanced (skewed) sleep duration, frequent short or long hours, was associated with higher mean CRP for all women and non-white women (99.3%, 95%CI 17.2,238.9 and 126.7%, 95%CI 3.1,398.2, respectively), but lower total cholesterol (-10.9%, 95%CI -19.9,-1.0). Finally, irregular sleep durations, extreme short and long sleep bouts (kurtosis), were associated with reduced mean HDL for all women, and non-white women (-17.1%, 95%CI -31.1,-0.2 and -25.4%, 95%CI -39.5,-8.0, respectively).

Conclusion

This micro-longitudinal study of premenopausal women found associations between irregularities in sleep duration and differences in CRP, LDL, HDL and total cholesterol, but not with triglycerides. These data suggest that even in young and healthy women, irregularities in sleep duration could have a potential impact on cardiometabolic health.

Support (If Any)

Dr. Dunietz was supported by a Mentored Research Scientist Development Award from the National Heart, Lung, and Blood Institute (K01 HL144914). This work was supported in part by the Intramural Research Program of the NIH, Eunice Kennedy Shriver National Institute of Child Health and Human Development (authors KAM, JRF, EFS, SLM; The BioCycle Study was funded under the following intramural contracts: HHSN275200403394C HHSN275201100002I, and Task 1 HHSN27500001).

0716 Risk for Heart Failure with preserved Ejection Fraction in patients with or without Obstructive Sleep Apnea

Introduction

Approximately two out of three patients with Heart Failure with preserved Ejection Fraction (HFpEF) have co-morbid sleep apnea, but the risk of HFpEF in patients who test positive for obstructive sleep apnea (OSA) is unknown.

Methods

Referred subjects (n=228) over the age of 18 underwent a diagnostic in-lab polysomnogram at the University of Michigan Sleep Laboratories between 1/8/2019-3/11/2020 and an echocardiogram within 12 months of their sleep study. Individuals with a known history of HFpEF were excluded (n=44). OSA was defined as an apnea-hypopnea-index (AHI) ≥ 5/hour. Clinical and echocardiogram variables were abstracted from the electronic medical record and used to determine H2FPEF scores (ordinal scale, range 0-9). The H2FPEF score is a validated predictor of HFpEF risk in patients with dyspnea. In the presence of dyspnea, a H2FPEF score ≥ 3 indicates a >50% risk of HFpEF, though dyspnea was not assessed in this study. HFpEF probability (continuous variable) was determined using the corresponding online calculator. Linear regression was used to predict HFpEF probability based on AHI.

Results

The 184 subjects without a known diagnosis of HFpEF had a median age of 65 years (interquartile range (IQR) 51, 71). Seventy subjects (38%) were male, 150 (82%) had OSA, and the median AHI was 15 (7, 35). The median H2FPEF score was 3 (2, 5). Among 34 participants without OSA, 10 (29%) had an H2FPEF score ≥ 3, whereas among 150 participants with OSA, 59 (39%) had an H2FPEF score ≥ 3. Linear regression indicated that higher AHI is associated with a higher probability of HFpEF (β = 0.39, p=0.0001).

Conclusion

Many patients referred for polysomnography may be at high risk for HFpEF. Sleep-study-referred subjects without clinically-indicated echocardiograms were not assessed, but patients at sleep disorders centers who test positive for OSA may have a particularly high rate of undiagnosed HFpEF. Sleep physicians should consider a cardiology referral in appropriately screened patients.

Support (If Any)

 

0334 The Role of Race-Gender Intersectionality in Associations between Insomnia Patterns and Late-Life Memory Trajectories

Introduction

Difficulty initiating sleep (DIS) may be a stronger predictor of neurodegenerative risk than other insomnia symptoms. This study examined whether longitudinal patterns of DIS are associated with subsequent memory trajectories, and whether associations differ across non-Hispanic Black and White men and women.

Methods

12,565 participants in the Health and Retirement Study (Mage=67.8±9.1, 59.1% women) who self-identified as non-Hispanic Black (14.5%) or non-Hispanic White were included. DIS (“How often do you have trouble falling asleep?”) at three biennial waves (2002-2006) was dichotomized (“never/rarely/sometimes”=0, “often”=1). Participants were categorized into three mutually exclusive groups: low (reference group), persistent, and variable DIS. Episodic memory was assessed using a 10-item word list recall test at five biennial waves (2008-2016). Latent growth curves modeled associations between DIS patterns and subsequent memory level and change, adjusting for sociodemographics (model 1), health conditions (model 2), and depressive symptoms (model 3) in 2002. Stratified models compared associations across White men, Black men, White women, and Black women.

Results

Compared to low DIS, persistent (β=-0.03, p<.001) or variable (β=-0.07, p<.001) DIS was associated with worse subsequent memory in models 1 and 2. The effect of variable (β=-0.05, p<.001), but not persistent (β=-0.01, p=.271), DIS remained in model 3. Persistent DIS was most prevalent among White women (5.4% vs. 2.4-4%), and variable DIS was most prevalent among Black women (24.1% vs. 14-22.2%). Persistent DIS was only significantly associated with memory among White women (β=-0.04, p=.003 vs. β=-0.04, p=.324 for Black Men; β=-0.03, p=.087 for White men; and β=0.01, p=.859 for Black women). Variable DIS was most strongly associated with memory among Black men (β=-0.141, p=.003), followed by White men (β=-0.09, p<.001), White women (β=-0.06, p<.001) and Black women (β=-0.06, p=.064). There were no associations between DIS patterns and memory change.

Conclusion

While links between persistent DIS and subsequent memory may reflect negative cognitive effects of depression, variable DIS may presage worse memory above and beyond depression. Race/gender differences in the prevalence and predictive value of DIS patterns for subsequent cognitive function highlight the value of an intersectional lens. Gender disparities in DIS may be more prominent than racial disparities.

Support (If Any)

NIA F31AG067717 (PI: Zaheed)

415 Risk of Obstructive Sleep Apnea after Treatment of Head and Neck Squamous Cell Carcinoma

Introduction

Head and neck cancers (HNC) or their treatment may be associated with an increased risk of obstructive sleep apnea (OSA). Small studies that examined OSA risk factors in adults with HNC reported conflicting results. This study examined associations between tumor characteristics and risk of OSA among patients at least one year free of head and neck squamous cell carcinoma (HNSCC).

Methods

For this cross-sectional study of HNSCC patients at a large academic medical center, inclusion criteria were age ≥18 years, with absence of tracheostomy or mental impairment. The STOP-BANG questionnaire, with a threshold ≥3, was used to identify high risk for OSA. Descriptive statistics were used to compare demographic and health characteristics between OSA risk groups. Logistic and linear regression models adjusted for age and gender were used to examine associations between demographics, anthropometric measures, and OSA risk.

Results

Among 67 participants, 57 (85%) were male, mean age was 62.0±8.0 (s.d.) years, mean body mass index (BMI) was 28.7±4.6 Kg/m2, and mean neck circumference (NC) was 16.3±1.2 inches. A total of 50 (75%) participants received chemoradiation only. High OSA risk was observed in 40 (60%) of the participants. Tumor location, tumor stage, and type of cancer treatment were not different between OSA risk groups. Body mass index and NC were greater in the high OSA risk group (BMI 29.6±4.5 Kg/m2 vs. 27.3±4.1 Kg/m2, p=0.03; NC 16.5±1.3 inches vs. 15.8±0.5 inches, p=0.01). In age and gender-adjusted logistic regression models, BMI (OR=1.2, 95% CI 1.0, 1.4) and NC (OR=2.9, 95% CI 1.1, 7.3) were associated with high OSA risk. Adjusted linear regression models showed that BMI (β=0.10, 95%CI 0.04, 0.17) and NC (β=0.64, 95%CI 0.32, 0.96) were associated with STOP-BANG scores.

Conclusion

High OSA risk was quite common after HNSCC treatment. However, measured HNSCC characteristics were not different between high and low OSA risk groups. Instead, OSA risk factors included BMI and NC, as often reported in non-HNSCC patients as well. Prospective studies before and after cancer treatment will be needed to further elucidate potential roles of HNSCC and its treatment in subsequent OSA incidence.

Support (if any)

Dr. Gavidia’s work was supported by an NIH/NINDS T32-NS007222 grant.

470 Maternal Habitual Snoring and Blood Pressure Trajectories in Pregnancy

Introduction

Habitual snoring has been associated with hypertensive disorders of pregnancy. However, exactly when blood pressure (BP) trajectories diverge between pregnant women with and without habitual snoring is unknown. Moreover, the potentially differential impact of chronic versus pregnancy-onset habitual snoring on maternal BP trajectories during pregnancy has not been examined.

Methods

In a cohort study of 1,305 pregnant women from a large Midwestern medical center, participants were asked about habitual snoring (≥3 nights/week) and whether their symptoms began prior to or during pregnancy. Demographic and BP data throughout pregnancy, systolic (SBP) and diastolic (DBP) were abstracted from medical charts. Linear mixed models were used to examine associations between habitual snoring-onset and pregnancy BP trajectories.

Results

Thirty percent of women reported snoring before pregnancy (chronic snoring) and an additional 23% reported pregnancy-onset snoring. Overall, women with pregnancy-onset snoring had higher mean SBP and DBP compared to those with chronic habitual snoring or controls (non-habitual snoring). In gestational week-specific comparisons with controls, SBP became significantly higher around 20 weeks’ gestation among women with pregnancy-onset snoring and in the third trimester among women with chronic snoring. Pairwise mean differences in DBP were significant only among women with pregnancy-onset snoring relative to controls, after 15 weeks’ gestation.

Conclusion

In a large cohort of pregnant women, those with pregnancy-onset or chronic habitual snoring had significantly elevated systolic BP in comparison to non-habitual snoring controls, in the second and third trimester, respectively. The findings of divergent BP trajectories suggest the two groups of women with habitual snoring in pregnancy should be considered separately when evaluating gestational ‘windows’ for increased BP monitoring and provide insight into pathophysiologic changes.

Support (if any)

Dr. Dunietz was supported by an F32 National Research Service Award from the National Institute of Child Health and Development (NIH/NICHD F32 HD091938); Dr. O’Brien was supported by the following during the course of this study: the Gene and Tubie Gilmore Fund for Sleep Research, the University of Michigan Institute for Clinical and Health Research (MICHR) grants UL1RR024986 and UL1TR000433, MICHR seed pilot grant F021024, the National Heart, Lung, and Blood Institute (R21 HL089918 and K23 HL095739) and in part by R21 HL087819.

549 Associations of Bedtime, Wake-time and Employment Status by Gender and Race

Introduction

Poor sleep quality has been reported in the unemployed compared with employed. How sleep varies by employment status has been rarely examined at a population level. Therefore, we investigated sleep-wake patterns among employed, unemployed but actively seeking a job, and not-in-the-labor-force participants by gender and race/ethnicity.

Methods

Methods We used data from the American Time Use Survey (ATUS), a nationally representative sample of US residents aged ≥15years, which records weekday/weekend activities in a 24-hour period (4:00am-4:00am). This sample was restricted to participants aged 25–60 years (n=130,062). This analysis utilized functional nonparametric regression based on dimension reduction and neighborhood matching. We modeled the relationship between participant-specific sleep-wake trajectories, coded by minute, and employment status. Implementing the counterfactual approach, we estimated the effects of each employment scenario on participant-level expected sleep trajectory. This approach allowed the examination of hypothetical sleep-wake trajectories for each participant if their employment status differed from the observed. We then marginalized these findings to gender and race/ethnic subpopulations, controlling for confounders and secular trends.

Results

Mean age was 42□0.01 years, nearly half (51%) of participants were women and 68% were Whites. The proportions of employed, unemployed, and not-in-the-labor-force were 79%, 16.5% and 4.5%, respectively. On average, unemployed and not-in-the-labor-force participants had a later bedtime and wake-time compared with employed. With the exception of Whites, each individual race/ethnicity group showed pronounced differences in sleep-wake patterns by employment status. Of note, the likelihood of still being asleep up to 9:00am was greater when unemployed in comparison to had they been employed. Compared with employed, differences in sleep-wake patterns were pronounced among Blacks and Hispanics had they been unemployed, but attenuated if they were out-of-the-labor-force. Gender alone was not a strong moderator of the relationship between sleep-wake patterns and employment status. Unemployed participants had bedtime after 11pm, regardless of gender or race/ethnicity.

Conclusion

Using the counterfactual approach, we predicted sleep-wake patterns among individuals had they been employed, unemployed, or out-of-the-labor-force by gender and race/ethnicity. Though cross-sectional, our data suggest that the sleep schedules of racial/ethnic minorities in comparison to Whites may be more affected by employment status.

Support (if any):

537 Insomnia Symptoms and Subsequent Cognitive Performance in Older Adults: Are Depressive Symptoms and Vascular Disease Mediators?

Introduction

Alzheimer’s disease and related dementias (ADRD) are growing public health concerns, and poor sleep may represent a modifiable risk factor. However, there is limited research on insomnia as a predictor of subsequent performance in different cognitive domains and mechanisms that might underlie domain-specific associations. The current study examined: (1) which insomnia symptoms predicted performance across five cognitive domains 14 years later, and (2) whether depressive symptoms and/or vascular diseases mediated these associations.

Methods

Participants included 2,496 adults aged 51+ in the Health and Retirement Study. Insomnia symptoms in 2002 (i.e., “baseline”) were quantified by four self-reported items on frequency of trouble falling asleep, nighttime awakenings, early awakenings, and feeling rested upon awakening. Cognition was assessed in 2016 as part of the Harmonized Cognitive Assessment Protocol and operationalized with five factor scores corresponding to episodic memory, executive function, language, visuoconstruction, and processing speed. Multiple regressions examined associations between baseline insomnia symptoms and subsequent cognitive performance, controlling for sociodemographics and baseline global cognitive performance. Mediation models tested whether associations were explained by self-reported depressive symptoms and/or vascular diseases (i.e., hypertension, heart disease, diabetes, and/or stroke) in 2014, controlling for baseline values.

Results

Only trouble falling asleep in 2002 was associated with cognition in 2016. Specifically, more frequent trouble falling asleep predicted poorer episodic memory, executive function, language and processing speed performance, but not visuoconstruction. These associations were mediated by depressive symptoms and vascular diseases in 2014 for all domains except episodic memory; only depressive symptoms mediated the association involving memory. After accounting for these mediators, direct effects of trouble falling asleep remained for episodic memory, executive function and language, but not processing speed.

Conclusion

Difficulty with sleep initiation may be more consequential for later-life cognition than other insomnia symptoms. Depressive symptoms and vascular diseases may partially drive these associations. We speculate that sleep-onset insomnia could mean less total sleep, immune dysfunction, or endocrine effects that worsen mood, vascular health, and cognition. Remaining associations indicate that additional research is needed to characterize other mechanisms through which sleep initiation problems could contribute to later impairments in frontal and temporal cognitive systems, which are implicated early in ADRD.

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Abstract P597: Growing Prevalence of Post-Stroke Sleep-Disordered Breathing

Introduction: Sleep-disordered breathing (SDB) is common after stroke and is associated with poor functional and cognitive outcomes, and recurrent stroke. Despite increasing prevalence of SDB in the general population, no data are available about trends in post-stroke SDB. We therefore sought to assess changes in post-stroke SDB prevalence over a 10-year period.

Methods: Within the Brain Attack Surveillance In Corpus Christi (BASIC) project, a population-based stroke surveillance study in south Texas, participants with acute ischemic stroke were offered assessment of SDB with the ApneaLink Plus device. Medical record abstraction and baseline interviews were conducted and included the Berlin questionnaire to assess SDB status in reference to the prestroke state. SDB testing was performed shortly after stroke presentation (median 12 days (IQR: (6, 21)). Respiratory event index (REI) was calculated as the sum of apneas and hypopneas per hour of overnight recording. SDB was defined as an REI ≥10. SDB assessment procedures remained unchanged throughout (2010-2020). Logistic (SDB) and linear (REI) regression were used to test associations with time (parameterized as years since 2010) adjusted for demographics, and stroke and SDB risk factors including BMI and pre-stroke SDB status.

Results: Among the 1,197 participants, median age was 65, 53% were male, and 65% were Mexican American. SDB prevalence was 61% in 2010-2011 and 75% in 2018-2019. Median REI was 19 in 2010-2011 and 23 in 2018-2019. A linear association was identified between time and SDB (REI≥10), with an odds ratio of 1.123 (95% CI: 1.062, 1.187) per year, after adjustment. Similarly, a linear association was identified between time and REI, with an average increase of 0.504 (95% CI: 0.148, 0.860) per year, after adjustment. Based on models with interaction terms added, no differences in time trends were found by sex or ethnicity.

Conclusions: Post-stroke SDB prevalence in this population-based sample has increased over the last 10 years. These data highlight the importance of post-stroke SDB and the pressing need to determine whether its treatment improves outcomes.

Abstract TMP79: Pre-Stroke Sleep Apnea and Post-Stroke Depression

Introduction: Sleep apnea is an independent risk factor for stroke and strongly associated with depression; however, little is known about its role in predicting depression after stroke among stroke survivors. This study examined the association between pre-stroke sleep apnea risk and depression at 90 days post-stroke in a population-based sample.

Methods: Data were obtained from the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based stroke study in south Texas. The study sample consisted of 1,383 participants who had ischemic or hemorrhagic stroke between August 2010 and December 2016. Depression after stroke was measured by the 8-item Patient Health Questionnaire (range: 0-24). Participants scoring 10 or above were classified as having depression. Pre-stroke sleep apnea risk assessed at stroke onset was classified as high or low based on Berlin Questionnaire scores (high risk: 2 or more categories with a positive score; low risk: 0-1 category with a positive score). Inverse probability weighting and multiple imputation were used to deal with attrition and missing covariate data. Weighted logistic regression models were used to examine the association between pre-stroke sleep apnea risk and post-stroke depression.

Results: Mean age of participants was 68.1 years (SD=12.3), men and women were evenly distributed, 59.4% were Mexican American, and 59.2% were at high risk for sleep apnea before stroke. High-risk participants were significantly more likely to be men, Mexican American, obese and on medication for depression at the time of stroke. Pre-stroke sleep apnea risk was associated with post-stroke depression (Odds Ratio [OR]=1.78, 95% Confidence Interval [CI]=1.38-2.29), even after adjustment for sociodemographic characteristics, smoking, obesity, pre-stroke depression status and stroke severity (OR=1.60, 95% CI=1.19-2.14).

Conclusions: Pre-stroke sleep apnea may be an independent risk factor for post-stroke depression. Treatment of sleep apnea before or perhaps even after stroke may reduce risk for depression after stroke.

Abstract WP216: Predicting Sleep Apnea After Ischemic Stroke

Introduction: Sleep apnea (SA) is highly prevalent after stroke and is associated with poor stroke outcomes. Currently, after stroke, a physiological test must be used to differentiate patients with and without SA. Within a large, population-based study, we tested the usefulness of statistical models based on baseline characteristics to predict SA.

Methods: Within the Brain Attack Surveillance in Corpus Christi (BASIC) project, participants with ischemic stroke (2010-2018) underwent SA screening, shortly after stroke, with the ApneaLink Plus portable sleep apnea testing device. The respiratory event index (REI) was calculated as the number of apneas and hypopneas per hour of recording; values ≥10 defined SA. Logistic regression and the Distributed Random Forest Classifier (a machine learning technique) were applied to predict SA with the following as predictors: demographics, stroke risk factors, stroke severity (NIHSS), neck and waist circumference, palate position, and pre-stroke symptoms of snoring, apneas, and sleepiness. Models were internally validated with cross-validation.

Results: Within the total sample (n=1,330), median age was 65; 47% were women; 32% non-Hispanic white, 62% Mexican American, and 6% African American. SA was found in 67%. The area under the receiver operating characteristic curve, a measure of predictive ability, applied to the validation sample, was 0.69 for logistic regression and 0.74 for the random forest model. Random forest correctly classified 72.3% of validation samples, while logistic regression correctly classified 70.7% of validation samples. The most important features for predicting SA were waist circumference, neck circumference, body mass index, NIHSS, and pre-stroke daytime sleepiness.

Conclusions: In this large, ethnically diverse, population-based sample of ischemic stroke patients, prediction models based on easily obtained baseline characteristics and simple measurements resulted in fair performance, despite use of advanced statistical and machine learning techniques. Physiological tests are still needed to differentiate ischemic stroke patients with and without SA.

Abstract TP179: Selecting an Outcome for Sleep Apnea Treatment Trials in Stroke: A Comparative Analysis

Introduction: Post-stroke sleep apnea (SA) affects the majority of stroke patients and is associated with poorer stroke outcomes. To select appropriate endpoints for a future SA treatment trial in stroke patients, we assessed the predictive ability between a variety of important outcome measures and SA severity, as measured by the apnea-hypopnea index (AHI), within a population-based stroke study.

Methods: Ischemic stroke patients enrolled in the Brain Attack Surveillance in Corpus Christi (BASIC) project were offered SA screening shortly after stroke with a portable sleep apnea test (ApneaLink Plus). Apnea-hypopnea index (AHI) was calculated as the sum of apneas and hypopneas during the nocturnal recording. Subjects had baseline information collected from chart abstraction and interview, and had 3-month outcomes assessed in-person including an activities of daily living (ADL)/instrumental ADL(IADL) scale, NIHSS, Modified Mini-Mental State exam (3MS), and 12-item Stroke-specific Quality of Life scale (SSQOL). Predictive R 2 (a measure of how well models predict responses for new observations) from linear regression models was used to compare predictive ability of models with and without AHI, adjusted for significant predictors of outcome.

Results: Within 455 subjects, the predictive R 2 was 31.7% for ADL/IADL, 23.2% for SSQOL, 25.0% for the 3MS, and 11.7% for NIHSS in the model without AHI. When AHI was included in the models, the predictive R 2 increased to 32.8% for ADL/IADL and increased to 11.9% for NIHSS; however, the predictive R 2 decreased by 0.1% for SSQOL and decreased by 0.2% for 3MS.

Conclusions: In future trials that test SA treatment’s effect on stroke outcomes at 3 months, improvement is most likely to be observed from a functional outcome, such as that measured by the ADL/IADL scale.

Abstract WMP59: Sleep Apnea is Associated with the Combined Endpoint of Recurrent Stroke and Post-Stroke Mortality

Introduction: No data are available about the relationship between sleep apnea (SA) and recurrent stroke and mortality from population-based studies, large samples, or ethnically diverse populations.

Methods: In the Brain Attack Surveillance in Corpus Christi (BASIC) project, we identified patients with ischemic stroke between 2010-2015. Subjects who enrolled were offered screening for SA with the ApneaLink Plus device from which an apnea-hypopnea index (AHI) was derived (≥10 defined SA). Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance and confirmed by study neurologists. All-cause mortality was identified through Texas Department of State Health Services records. Cox proportional-hazards models were used to assess the association between AHI (modeled linearly) and combined ischemic stroke recurrence and mortality unadjusted and adjusted for multiple potential confounders.

Results: Of the 842 subjects, the median age was 65 (IQR: 57, 76), 47% were female, 58% were Mexican American, and 34% were non-Hispanic white. The median AHI was 14 (IQR: 6, 26); 63% had SA. SA was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes, hypertension, lower educational attainment, and higher BMI. In the time period (median time to event 584 days), 90 (10.7%) recurrent strokes and 125 (14.8%) deaths occurred with a cumulative incidence of recurrence or death of 202 (24%). AHI was associated with the combined endpoint in unadjusted (HR=1.09 per one unit increase in AHI (95%CI: 1.08, 1.10)) and fully adjusted models (HR=1.09 (95%CI: 1.08, 1.10)). Mexican American ethnicity was associated with the endpoint (HR=1.71 (95%CI: 1.16, 2.54) in the fully adjusted model.

Conclusion: SA is associated with the combined endpoint of recurrent ischemic stroke and mortality in this population-based study. Mexican Americans are also at higher risk of recurrent stroke and death following ischemic stroke than non-Hispanic whites. SA may therefore represent an important modifiable risk factor for poor stroke outcomes and a target to reduce ethnic stroke disparities.

Abstract WP272: Sleep-disordered Breathing is Associated With Worse Stroke Outcomes in Mexican Americans

Objective: Post-stroke sleep-disordered breathing (SDB) is prevalent and may be linked to poor stroke recovery but population-based studies in diverse populations are lacking. Our objective was to examine the association between SDB measured soon after stroke and stroke outcomes and to determine whether associations vary by ethnicity in the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project.

Methods: Ischemic stroke (IS) patients were offered SDB screening with the ApneaLink Plus™; SDB was defined as apnea-hypopnea index (AHI) ≥ 10 events per hour. Patient data were collected from interviews and medical records. Functional, neurologic, cognitive, and quality of life (QOL) outcomes were ascertained at 90-days by patient or proxy interviews. Regression models were used to examine associations between SDB and outcomes adjusted for confounders. Interaction terms were used to investigate differences by ethnicity.

Results: 232 NHW and 393 MA IS patients had a successful SDB screening and completed a 90-day interview. Median age was 65 years (IQR:58-75) among MAs and 67 (IQR:58-77) among NHWs. Post-stroke SDB was 68.7% in MAs [median AHI: 16 (IQR:8-26)] and 52.6% in NHWs [median AHI: 10 (IQR:6-23)]. Patients with SDB were more likely to be MA and to have diabetes, hypertension, and higher BMI but less likely to smoke than those without SDB. SDB was associated with worse functional, neurologic, cognitive, and QOL outcomes in MAs but not NHWs (Table).

Conclusions: SDB is associated with worse stroke outcomes in MAs but not NHWs, the reasons for which should be explored. SDB treatment in MAs may improve outcomes in this subgroup and lessen ethnic stroke outcome disparities.

Promoting Sleep Health Among Families of Young Children in Head Start: Protocol for a Social-Ecological Approach

Inadequate or poor quality sleep in early childhood impairs social-emotional and cognitive function via effects on the developing brain and increases obesity risk via hormonal and endocrine effects. The prevalence of short sleep duration, behavioral sleep problems, and sleep-disordered breathing among children aged 3 to 5 years is 20% to 50%. Healthy sleep habits increase sleep duration and prevent behavioral sleep problems. Awareness of sleep-disordered breathing symptoms leads to its timely treatment. We designed a study that aims to empower families whose children are in early childhood programs with the knowledge and skills needed to obtain healthy sleep and to recognize a sleep problem. We used the social-ecological framework to guide individual, interpersonal, organizational, community, and policy interventions. This study builds on the Sweet Dreamzzz, Inc, Early Childhood Sleep Education Program (ECSEP) in Head Start. A stepped-wedge-cluster randomized trial will test effects on child, parent, and classroom outcomes; a policy evaluation will assess the impact of knowledge-translation strategies. The study has 3 aims. The first is to adapt educational materials into multimedia formats and build the capacity of Head Start agencies to implement the study. The second aim is to enroll 540 parent-child dyads in a primary prevention trial of sleep health promotion in Head Start and to analyze effects on children's sleep duration (primary outcome); parents' knowledge, attitudes, self-efficacy, and behavior; and children's sleep difficulties. The third aim is to conduct a secondary prevention feasibility study of screening and guidance for sleep problems. Secondary outcomes are changes in classroom behaviors and policies. Integrating sleep health literacy into early childhood programs could affect the life-course development of millions of children.

Confronting Drowsy Driving: The American Academy of Sleep Medicine Perspective

ABSTRACT

Drowsy driving is a serious public health concern which is often difficult for individual drivers to identify. While it is important for drivers to understand the causes of drowsy driving, there is still insufficient scientific knowledge and public education to prevent drowsy driving. As a result, the AASM is calling upon institutions and policy makers to increase public awareness and improve education on the issue, so our society can better recognize and prevent drowsy driving. The AASM has adopted a position statement to educate both healthcare providers and the general public about drowsy driving risks and countermeasures.

Prevalence of pre-stroke sleep apnea risk and short or long sleep duration in a bi-ethnic stroke population

BACKGROUND

The ethnic disparity in ischemic stroke between Mexican Americans (MAs) and non-Hispanic whites (NHWs) may be partly attributable to disparities in sleep and its disorders. We therefore assessed whether pre-stroke sleep apnea symptoms (SA risk) and pre-stroke sleep duration differed between MAs and NHWs.

METHODS

MA and NHW ischemic stroke survivors in the Brain Attack Surveillance in Corpus Christi (BASIC) project reported sleep duration and SA symptoms on the validated Berlin questionnaire, both with respect to their pre-stroke baseline. Log binomial and linear regression models were used to test the unadjusted and adjusted (demographics and vascular risk factors) associations of high-risk Berlin scores and sleep duration with ethnicity.

RESULTS

Among 862 subjects, 549 (63.7%) were MA and 514 (59.6%) had a high risk of pre-stroke SA. The MA and NHW subjects showed no ethnic difference, after adjustment for potential confounders, in pre-stroke SA risk (risk ratio (95% confidence interval (CI)): 1.06 (0.93, 1.20)) or in pre-stroke sleep duration (on average MAs slept 2.0 fewer minutes than NHWs, 95% CI: -18.8, 14.9 min).

CONCLUSIONS

Pre-stroke SA symptoms are highly prevalent, but ethnic differences in SA risk and sleep duration appear unlikely to explain ethnic stroke disparities.

Approach to and evaluation of sleep disorders

PURPOSE OF REVIEW

This article provides a framework for the clinical assessment of patients with sleep-related complaints and outlines a systematic approach to a sleep-specific history and physical examination, subjective assessment tools, and diagnostic testing modalities.

RECENT FINDINGS

Physical examination findings may suggest the presence of a sleep disorder, and obstructive sleep apnea in particular, but the clinical history remains the most important element of the assessment for most sleep problems. While nocturnal polysomnography in a sleep laboratory remains the gold standard for diagnosis of sleep-disordered breathing, out-of-center testing may be considered when the clinician has a high pretest suspicion for obstructive sleep apnea and the patient has no significant cardiopulmonary, neuromuscular, or other sleep disorders.

SUMMARY

Sleep-related symptoms are common in adult and pediatric patients. A comprehensive sleep history, physical examination with detailed evaluation of the head and neck, and judicious use of sleep-specific questionnaires guide the decision to pursue diagnostic testing. Understanding of the benefits and limitations of various diagnostic modalities is important as the spectrum of testing options increases.

Patient Powered Device for the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea is a common sleep disorder in which throat muscles relax during sleep, causing the upper airway to close. As a result, breathing ceases until a brief awakening restores the muscle tone and reopens the airway. Untreated sleep apnea contributes to cognitive, cardiovascular, and metabolic morbidity and has substantial negative impact on an individual’s quality of life. Treatment most commonly consists of nightly use of a nasal mask connected to a continuous positive airway pressure (CPAP) machine. The CPAP machine splints the upper airway open by supplying positive air pressure. However, the machine is expensive, requires electricity, and has suboptimal portability, noise, and aesthetics. The aim of this work was to develop a low-cost, lightweight, quiet, and mechanical CPAP machine that would function without an external energy source in resource-limited settings.

The use of pharmacotherapy in the treatment of pediatric insomnia in primary care: rational approaches. A consensus meeting summary

OBJECTIVES

To formulate a rational approach to the pharmacologic treatment of pediatric insomnia, and to develop clinical guidelines regarding indications, target populations, and parameters for the use of these medications, especially by community-based pediatricians.

PARTICIPANTS

A multidisciplinary task force developed under the auspices of the American Academy of Sleep Medicine, which included experts in pediatric sleep medicine, psychiatry, pharmacology, neurology, and general pediatrics.

EVIDENCE

Review of existing data regarding current use of over-the-counter and prescription medications for pediatric insomnia in the primary care practice setting, and of empirical data on the pharmacology, safety, efficacy, and tolerability of medications commonly used for the treatment of pediatric insomnia.

CONSENSUS PROCESS

Group consensus definition of pediatric insomnia and clinical guidelines; working group recommendations regarding special populations and future directions.

CONCLUSIONS

Use of medications for pediatric insomnia should be diagnostically driven, and should be implemented in conjunction with empirically-based behavioral treatment strategies and adequate sleep hygiene. Specific target populations include children with neurodevelopmental disorders, pervasive developmental disorders, chronic medical conditions, and psychiatric disorders. Additional research, including clinical trials, is critically needed to provide an evidence-based approach to the use of these medications in clinical practice.

Radiofrequency (pacing and thermic effects) in the treatment of sleep-disordered breathing

Radiofrequency, whether it is used for pacing or for its thermal liberation properties, has been investigated as a treatment for sleep-disordered breathing. Diaphragmatic pacing has a long history. The problems associated with pacing, which are related to patient selection, equipment failure, disturbances at the electrode/nerve interface, neuromuscular function failure, muscle fatigue, and the physiological consequences of stimulation, will have to be resolved with XIIth nerve stimulation. Radiofrequency thermal ablation has been applied on the tongue of an animal model. In man, turbinates, soft palate tissue and the base of tongue have been treated. These feasibility studies have demonstrated that obstructive sleep apnea syndrome and upper airway resistance syndrome can be completely controlled using radiofrequency thermal ablation in some subjects. These results can be obtained without complications related to speech, taste or swallowing. The treatment can be administered as an outpatient procedure, but many applications are needed, and treatment may span 6 months. Too high a level of radiofrequency will cause pain or otherwise avoidable complications. The determination of which patients will benefit most from these procedures will require further multi-center, placebo-controlled studies.

Upper airway sleep-disordered breathing in women

OBJECTIVE

To investigate the various clinical presentations of sleep-disordered breathing in women.

DESIGN

A retrospective case-control study.

SETTING

A sleep disorders clinic.

PATIENTS

334 women, aged 18 years and older, seen between 1988 and 1993, who were diagnosed with upper airway sleep-disordered breathing. Controls were 60 women with insomnia and 100 men with sleep-disordered breathing.

MEASUREMENTS

Clinical, anatomic, and polygraphic information.

RESULTS

The mean lag time (+/- SD) in women between the appearance of symptoms and a positive diagnosis was 9.7 +/- 3.1 years; among participants 30 to 60 years of age, the duration of untreated symptoms differed (P < 0.001) between women and men. Sleep-disordered breathing was blamed for divorce or social isolation by 40% of the case patients. Abnormal maxillomandibular features were noted in 45% of the women with disordered breathing. Dysmenorrhea and amenorrhea (which disappeared after treatment with nasal continuous positive airway pressure) were reported in 43% of premenopausal women compared with 13% of persons in the control group of women with insomnia. Thirty-eight women (11.4%) with upper airway sleep-disordered breathing had a respiratory disturbance index of less than 5 and were significantly younger, had a smaller neck circumference, and had a lower body mass index than women with a respiratory disturbance index of 5 or more.

CONCLUSION

Physicians should revise their understanding of upper airway sleep-disordered breathing so that they notice women with certain craniofacial features, a low body mass index, a small neck circumference, and a respiratory disturbance index of less than 5. These revisions may enable more rapid diagnosis and treatment of women with sleep-disordered breathing.