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The Effects of Sleep Apnea on Alzheimer’s Disease

posted Jun 8, 2016, 12:40 AM by Admin SRSAN

Sleep Apnea can be considered a modifiable risk factor for Alzheimer’s disease, according  to a 2015 paper published in the Journal of Neuroscience Research  (Daulatzai 2015).

Alzheimer’s dementia is an irreversible neurodegenerative condition characterized by deposition of amyloid B plaques and neurofibrillary tangles in the brain, with widespread synaptic damage and cognitive dysfunction.

While the mechanisms by which obstructive sleep apnea  contributes to Alzheimer’s disease are not completely understood, they appear to involve  both hypoxic damage and inflammation, promoting lower perfusion and reduced metabolism of the cortex and hippocampus, formation of amyloid B plaques and synaptic dysfunction.  These processes reduce the structural integrity and lead to atrophy of several brain regions, including the medial temporal lobe and hippocampus, which are essential to memory functions.

In another 2015 paper, Gelber et al. show that reduced slow wave sleep (N3 stage) due to sleep fragmentation is associated with more neuronal loss and brain atrophy,  as well as more cognitive decline in men.  Sleep duration with blood oxygenation below 95% was associated with a much higher risk of microinfarcts (almost 4 times greater, when comparing the highest to lowest quartile).    Since both reduced slow wave sleep and blood oxygenation levels below 95% are common in obstructive sleep apnea, this study corroborates Daulatzai’s conclusion that sleep-disordered breathing contributes to cognitive decline in Alzheimer’s dementia.

 

Sources:



Daulatzai, Mak Adam. "Evidence of neurodegeneration in obstructive sleep apnea: Relationship between obstructive sleep apnea and cognitive dysfunction in the elderly." Journal of neuroscience research 93.12 (2015): 1778-1794.

Gelber, Rebecca P., et al. "Associations of brain lesions at autopsy with polysomnography features before death." Neurology 84.3 (2015): 296-303.


Depression symptoms may be improved by treatment with CPAP or Oral Appliance Therapy

posted Jun 8, 2016, 12:37 AM by Admin SRSAN


A couple of recent studies by Cheng and Hayley show that obstructive sleep apnea is approximately five times more common in patients with depression than in control participants  and conversely, that patients with obstructive sleep apnea are  5 times  more likely to report depression.  (Cheng et al. 2013,   Hayley et al. 2015,  Wheaton et al.  2012). 

There are several mechanisms likely to account for these findings: the sleep disruption and weight gain that are often associated with depression could cause or worsen obstructive sleep apnea; at the same time, obstructive sleep apnea could trigger or exacerbate depression by causing sleep disruption and inducing cognitive changes by intermittently starving the brain of oxygen (Povitz 2014).

Sleep apnea and depression share many common symptoms – persistent fatigue, daytime sleepiness, low vitality and concentration problems. According to Carol Lang, a University of Adelaide researcher who studies the link between sleep apnea and depression, women have more depression than men and women with obstructive sleep apnea have more severe depression symptoms (Doheny, 2015).

However, treatment with CPAP or Oral Appliance Therapy tends to result in a significant  improvement in depressive symptoms (Povitz et al. 2014). According to Povitz, the greatest improvement has been observed in those patients  with the most severe  depression - paving the way to new therapeutic modalities  for this highly prevalent condition.

 

Sources:



Cheng, Philip, et al. "Sleep‐disordered breathing in major depressive disorder." Journal of sleep research 22.4 (2013): 459-462.

Hayley, Amie C., et al. "The relationships between insomnia, sleep apnoea and depression: findings from the American National Health and Nutrition Examination Survey, 2005–2008." Australian and New Zealand journal of psychiatry 49.2 (2015): 156-170.

Wheaton, Anne G., et al. "Sleep disordered breathing and depression among US adults: National Health and Nutrition Examination Survey, 2005–2008."Sleep 35.4 (2012): 461-467.

Povitz, Marcus, et al. "Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis." PLoS Med11.11 (2014): e1001762.

Doheny,  Katleen HealthDay News       Sleep apnea may boost depression risk in men.   http://www.khq.com/story/29093823/sleep-apnea-may-boost-depression-risk-in-men. May 18, 2015

Mobile Apps Assist Physicians with Sleep Screening, Patients with Compliance

posted May 22, 2015, 11:41 AM by Admin SRSAN   [ updated May 22, 2015, 11:49 AM ]



A new mobile app (MySleep101) has been developed by a neurologist and a board-certified sleep physician at the Johns Hopkins Center for Sleep. The learning application offers healthcare teams that are not trained in sleep medicine basic information about the 7 most common conditions resulting in poor sleep quality: sleep apnea, restless leg syndrome, insomnia, hypersomnia, circadian rhythm disorders, post-traumatic stress disorder and parasomnia. The app covers signs and symptoms, risk factors, treatment options and management strategies that physicians can discuss with their patients at the screening stage - however the authors caution that this is an educational, not a diagnostic tool and that this initial assessment should be followed by referral to a board-certified sleep specialist in cases with a suspected sleep disorder. Both MySleep101 and MySleep101 Lite, which is available for free, are available through the Johns Hopkins Technology Ventures offices or the AppStore for iOS devices.

Help is also on the way for patients struggling with CPAP use. A new study shows that users of Phillips Respironics' SleepMapper app were 22 percent more adherent to continuous positive airway pressure therapy than non-users. SleepMapper, which is available both as a mobile app and website platform, gives patients access to the usage data generate by their CPAP machine, then presents patients with feedback and specific goals which attempt to increase adherence through a behavior-changing protocol called Motivational Enhancement Therapy. Using the benchmark compliance standards established by the Center for Medicare and Medicaid Services (which require that the patient uses the device four or more hours per night over 70 percent of the nights across a 30-day consecutive period within the first 90 days of treatment), the study found that only 56 percent of the non-SleepMapper users met the CMS guidelines (which is typical for the industry); however in the group using the SleepMapper app, a surprising 78 percent of patients met CMS adherence criteria - a difference of 22 percent. The greatest effect was noted in patients classified as "struggling", who used CPAP for an average of less than 2 hours a night in the first two weeks of treatment: in that particular group, CMS compliance was 33% for SleepMapper users, compared to 11 percent of non-users. Given that the impact of CPAP therapy on health outcomes tends to be proportional to the duration of use and that proof of compliance based on CMS standards is now required for insurance reimbursement, SleepMapper technology may provide critically needed assistance to patients struggling to meet these criteria and successfully implement CPAP therapy in their daily routine.

Sources:

http://www.sleepreviewmag.com/2015/04/johns-hopkins-mobile-app-helps-physicians-identify-common-sleep-disorders/

http://mobihealthnews.com/33742/philips-finds-sleepmapper-app-boosts-cpap-adherence-22-percent/

MATRx Oral Appliance Titration Technology Moving Closer to In-Home Applications

posted May 22, 2015, 11:39 AM by Admin SRSAN   [ updated May 22, 2015, 11:41 AM ]



The introduction of Zephyr Sleep Technologies' MATRx titration system in 2012 revolutionized the field of dental sleep medicine. For the first time, a single-night test in the sleep lab allowed the treating provider to determine with a high degree of accuracy whether the patient would respond to a mandibular repositioning device, as well as the target protrusive position required to achieve successful resolution of the obstructive sleep apnea. This approach allowed treating dentists and physicians to select those cases with a high probability of success, advance much more rapidly to the therapeutic position and avoid over-titration - reducing side effects and delivering effective treatment from day one - comparable to CPAP therapy.

The MATRx system uses a custom-fitted mandibular repositioning appliance that is remote-controlled by a sleep technician during a one-night polysomnogram session, according to a precise protocol which produces small incremental adjustments in mandibular position without disrupting the patient's sleep. In keeping with industry trends, this groundbreaking technology is now being adapted for in-home titration tests: the Zephyr team led by Dr. John Remmers has just completed a new clinical trial (150 patients) "demonstrating the feasibility of carrying out a computer-controlled mandibular titration (CCMP) test safely in an unattended setting, with an accuracy comparable to MATRx". With the clinical trial complete, the company is now moving into the product development stage, according to Paul Cataford, CEO and co-founder of Zephyr.

Source: http://zephyrsleep.com/award-winning-research/

CPAP Therapy Effect May be Comparable to Oral Diabetes Medication

posted May 22, 2015, 11:38 AM by Admin SRSAN   [ updated May 22, 2015, 11:41 AM ]



A study conducted at the University of Chicago demonstrated that with optimal use, one week of CPAP therapy reduced the mean 24-hr glucose levels and improved post-breakfast glucose response, as well as lowering the "dawn phenomenon" by 45% in type 2 diabetic patients with obstructive sleep apnea. In some patients, these effects were comparable to those produced by prescribed oral medications - a significant finding given that approximately 70% of type 2 diabetes patients suffer from OSA.

The National Health Sleep Awareness Project, an initiative funded by the Centers for Disease Control and Prevention in collaboration with the American Academy of Sleep Medicine, is advising all patients with Type 2 diabetes to be aware of their increased risk for obstructive sleep apnea, look for warning signs such as snoring, gasping or choking in their sleep and/or excessive daytime sleepiness, and talk to their doctor about further screening or testing for this chronic condition. According to Dr. Morgenthaler, president of the American Academy of Sleep Medicine, diagnosis and effective treatment of obstructive sleep apnea can improve glucose control and insulin sensitivity, helping patients better manage their diabetes.

Source: http://www.aasmnet.org/articles.aspx?id=5175

CPAP Therapy - A Possible Answer to Drug-Resistant Hypertension

posted May 15, 2015, 2:42 PM by Admin SRSAN   [ updated May 22, 2015, 11:46 AM ]

CPAP treatment could provide a solution to patients suffering from drug-resistant hypertension, according to a recent meta-analysis which looked at a multi-study pool of 300 patients using CPAP for a period between 3 weeks and 6 months. Obstructive sleep apnea has a striking prevalence of 83% in patients with drug resistant hypertension (high blood pressure which does not respond to three or more medications). While a number of studies have demonstrated statistically significant but modest improvement in blood pressure with CPAP therapy, the 2014 meta-analysis published in the Journal of Hypertension showed that for this difficult to treat population, the beneficial changes in systolic and diastolic blood pressure were considerably greater. Specifically, the study found a mean reduction of 7.21 mmHg in ambulatory systolic blood pressure (SBP), and 4.99mmHg in ambulatory diastolic blood pressure (DBP) from baseline after using CPAP therapy. While further research is needed to corroborate these findings, the study's principal investigator, Dr. Ulysses Magalang, hypothesizes that "untreated sleep apnea may be why these people haven’t seen improvement in their blood pressure despite the concurrent use of three or four medications”. Furthermore, the authors believe that "the longer the CPAP is used during the night, the greater the impact,” stressing the need for increased monitoring and support to improve treatment compliance. These changes could translate into a significant reduction in the risk of heart attack and stroke, and possibly a reduction in the medication burden, according to the study's authors, who urge more aggressive screening for sleep apnea in this population.



Sources

Iftikhar, Imran H., et al. "Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis." Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 9.2 (2013): 165.

Sleep Review Magazine, April 6, 2015. "In Resistant Hypertension, Sleep Apnea Treatment Results in Greater Blood Pressure Reduction"

Increased Risk of Osteoporosis in Sleep Apnea Patients

posted May 15, 2015, 2:40 PM by Admin SRSAN   [ updated May 22, 2015, 11:47 AM ]

The correlation between osteoporosis and obstructive sleep apnea (OSA) was the focus of two recent papers published in the Journal of Clinical Endocrinology and Metabolism and Sleep Medicine. Both studies were based on large population cohorts from the Taiwan National Health Insurance Database. In the first study, patients with newly diagnosed OSA and followed over a period of 6 years were found to have a 2.74 times greater risk of developing osteoporosis than patients without OSA, after adjusting for confounding variables (age, gender, diabetes, hypertension, coronary artery disease, obesity, stroke, hyperlipidemia, chronic kidney disease, gout, monthly income, and geographical location). Females and older patients had a greater risk of osteoporosis than males and younger populations. This highly statistically significant correlation is supported by the results of the second study, which found that the incidence rate of osteoporosis in sleep apnea patients was 9.97 vs 6.77 per 1000 person-years in patients without sleep-disordered breathing, with the greatest risk noted in females and those over 64 years of age. Because OSA is associated with metabolic, endocrine and cardiovascular disease mechanisms, Chen et al. hypothesized that the intermittent hypoxia characteristic of OSA pathophysiology is also responsible for disturbances in bone metabolism.


Sources:

Chen, Yu-Li, et al. "Obstructive sleep apnea and risk of osteoporosis: a population-based cohort study in Taiwan." The Journal of Clinical Endocrinology & Metabolism 99.7 (2014): 2441-2447.

Yen, Chia-Ming, et al. "Sleep disorders increase the risk of osteoporosis: a nationwide population-based cohort study." Sleep medicine 15.11 (2014): 1339-1344.

Poorer Diabetic Control in Patients with Obstructive Sleep Apnea

posted May 15, 2015, 2:37 PM by Admin SRSAN   [ updated May 26, 2015, 1:24 AM ]

A large multinational European study (ESADA) looking at the impact of obstructive sleep apnea on glycemic control in patients with Type 2 Diabetes Mellitus (T2DM) showed that T2DM prevalence increased with OSA severity, from 6.6% in subjects without OSA to 28.9% in those with severe OSA. After accounting for obesity and other confounding variables, a comparison with non-apneic patients found that the odds ratio for T2DM in mild, moderate and severe apnea were 1.33, 1.73 and 1.87 (P < .001), respectively. The severity of OSA also correlated with glycemic control: severe OSA patients had mean HbA1c levels that were 0.72% higher than those in diabetic patients without sleep-disordered breathing. The study authors concluded that sleep apnea severity is associated with an increased chance of co-existing Type 2 diabetes mellitus and with worse diabetic control.

Source: Kent, Brian D., et al. "Diabetes Mellitus Prevalence and Control in Sleep-Disordered Breathing: The European Sleep Apnea Cohort (ESADA) Study."CHEST Journal 146.4 (2014): 982-990.

CPAP Treatment Leads to Improvement in Glucose Metabolism in Diabetes Patients

posted May 15, 2015, 2:34 PM by Admin SRSAN   [ updated May 22, 2015, 11:47 AM ]

In a recently published case-controlled study of 150 CPAP-treated patients with OSA and type 2 diabetes, blood pressure and HbA1c levels were compared to those in matched patients who did not undergo CPAP therapy. After 5 years of treatment, the HbA1c level in the CPAP-treated group was 8.2%  vs. 12.1%  in the control group - a statistically significant difference that was accompanied by significantly lower blood pressure in the therapy group.

Corroborating these results, a 2014 review of 22 studies investigating the effect of CPAP treatment on patients with obstructive sleep apnea (OSA) and  Type 2 Diabetes Mellitus (T2DM) or prediabetes found that 77% of the studies demonstrated significant changes in glucose metabolism with prolonged use of CPAP.  Statistically significant changes were observed in HbA1C levels, postprandial or nocturnal glucose, and insulin sensitivity or resistance. In 4 out of the 17 studies showing improvement in glycemic control, these changes only manifested after 3 or more months of daily CPAP use, where compliance was defined as 4 or more hours of CPAP  treatment per night. Based on these results, the review concluded that CPAP therapy may contribute to Type 2 diabetes prevention, as well as help already diagnosed patients slow down the progression of the disease. 



Sources:

Gallegos, L., T. Dharia, and A. B. Gadegbeku. "Effect of continuous positive airway pressure on type 2 diabetes mellitus and glucose metabolism." Hospital practice (1995) 42.2 (2014): 31-37.

Guest, Julian F., et al. "Clinical outcomes and cost-effectiveness of continuous positive airway pressure to manage obstructive sleep apnea in patients with type 2 diabetes in the UK." Diabetes Care 37.5 (2014): 1263-1271
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