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Continuum (Minneapolis, Minn.) Aug 2023This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing,... (Review)
Review
OBJECTIVE
This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing, insomnia, parasomnias, restless sleep disorder, restless legs syndrome, narcolepsy in childhood, and Kleine-Levin syndrome.
LATEST DEVELOPMENTS
Our understanding of pediatric sleep pathophysiology continues to evolve, and diagnostic and treatment modalities have expanded. A low-sodium oxybate formulation was approved in July 2020 in the United States to treat cataplexy and excessive daytime sleepiness in patients 7 years old and older with narcolepsy. A validated pediatric hypersomnolence survey for pediatric narcolepsy and idiopathic hypersomnia with high sensitivity, specificity, and interrater reliability is now available.
ESSENTIAL POINTS
The clinical presentation, diagnostics, and treatment of children with sleep disorders differ from those of adults. Untreated sleep disorders in childhood can lead to adverse physical and psychological consequences in adults. Correctly diagnosing and treating sleep disorders in youth can prevent a significant burden of disease in adulthood.
Topics: Adult; Adolescent; Humans; Child; Reproducibility of Results; Parasomnias; Disorders of Excessive Somnolence; Narcolepsy; Cataplexy; Sodium Oxybate
PubMed: 37590830
DOI: 10.1212/CON.0000000000001285 -
The Psychiatric Clinics of North America Sep 2023Women have increased risks for both sleep disturbances and disorders and for mental health issues throughout their lives, starting in adolescence. Women have a higher... (Review)
Review
Women have increased risks for both sleep disturbances and disorders and for mental health issues throughout their lives, starting in adolescence. Women have a higher prevalence of insomnia disorder and restless legs syndrome (RLS) versus men, and obstructive sleep apnea (OSA) is more likely as women age. Hormonal transitions are important to consider in women's sleep. For women, insomnia, OSA, and RLS are predictive of depression, and insomnia and sleep-disordered breathing are predictive of Alzheimer disease. These findings underscore the importance of assessment, treatment, and future research examining sleep and mental health in women, given their unique and increased vulnerability.
Topics: Male; Adolescent; Humans; Female; Sleep Initiation and Maintenance Disorders; Mental Health; Sleep; Sleep Apnea, Obstructive; Women's Health; Restless Legs Syndrome; Prevalence; Sleep Wake Disorders
PubMed: 37500248
DOI: 10.1016/j.psc.2023.04.008 -
Revue Neurologique Oct 2023Idiopathic hypersomnia (IH) and Kleine-Levin syndrome (KLS) are rare disorders of central hypersomnolence of unknown cause, affecting young people. However, increased... (Review)
Review
Idiopathic hypersomnia (IH) and Kleine-Levin syndrome (KLS) are rare disorders of central hypersomnolence of unknown cause, affecting young people. However, increased sleep time and excessive daytime sleepiness (EDS) occur daily for years in IH, whereas they occur as relapsing/remitting episodes associated with cognitive and behavioural disturbances in KLS. Idiopathic hypersomnia is characterized by EDS, prolonged, unrefreshing sleep at night and during naps, and frequent morning sleep inertia, but rare sleep attacks, no cataplexy and sleep onset in REM periods as in narcolepsy. The diagnosis requires: (i) ruling out common causes of hypersomnolence, including mostly sleep apnea, insufficient sleep syndrome, psychiatric hypersomnia and narcolepsy; and (ii) obtaining objective EDS measures (mean latency at the multiple sleep latency test≤8min) or increased sleep time (sleep time>11h during a 18-24h bed rest). Treatment is similar to narcolepsy (except for preventive naps), including adapted work schedules, and off label use (after agreement from reference/competence centres) of modafinil, sodium oxybate, pitolisant, methylphenidate and solriamfetol. The diagnosis of KLS requires: (i) a reliable history of distinct episodes of one to several weeks; (ii) episodes contain severe hypersomnia (sleep>15h/d) associated with cognitive impairment (mental confusion and slowness, amnesia), derealisation, major apathy or disinhibited behaviour (hypersexuality, megaphagia, rudeness); and (iii) return to baseline sleep, cognition, behaviour and mood after episodes. EEG may contain slow rhythms during episodes, and rules out epilepsy. Functional brain imaging indicates hypoactivity of posterior associative cortex and hippocampus during symptomatic and asymptomatic periods. KLS attenuates with time when starting during teenage, including less frequent and less severe episodes. Adequate sleep habits, avoidance of alcohol and infections, as well as lithium and sometimes valproate (off label, after agreement from reference centres) help reducing the frequency and severity of episodes, and IV methylprednisolone helps reducing long (>30d) episode duration.
Topics: Adolescent; Humans; Kleine-Levin Syndrome; Idiopathic Hypersomnia; Disorders of Excessive Somnolence; Sleep; Narcolepsy
PubMed: 37684104
DOI: 10.1016/j.neurol.2023.08.010 -
Sleep & Breathing = Schlaf & Atmung Dec 2023The purpose of this study is to examine the pathophysiology underlying sleep apnea (SA). (Review)
Review
OBJECTIVE
The purpose of this study is to examine the pathophysiology underlying sleep apnea (SA).
BACKGROUND
We consider several critical features of SA including the roles played by the ascending reticular activating system (ARAS) that controls vegetative functions and electroencephalographic findings associated with both SA and normal sleep. We evaluate this knowledge together with our current understanding of the anatomy, histology, and physiology of the mesencephalic trigeminal nucleus (MTN) and mechanisms that contribute directly to normal and disordered sleep. MTN neurons express γ-aminobutyric acid (GABA) receptors which activate them (make chlorine come out of the cells) and that can be activated by GABA released from the hypothalamic preoptic area.
METHOD
We reviewed the published literature focused on sleep apnea (SA) reported in Google Scholar, Scopus, and PubMed databases.
RESULTS
The MTN neurons respond to the hypothalamic GABA release by releasing glutamate that activates neurons in the ARAS. Based on these findings, we conclude that a dysfunctional MTN may be incapable of activating neurons in the ARAS, notably those in the parabrachial nucleus, and that this will ultimately lead to SA. Despite its name, obstructive sleep apnea (OSA) is not caused by an airway obstruction that prevents breathing.
CONCLUSIONS
While obstruction may contribute to the overall pathology, the primary factor involved in this scenario is the lack of neurotransmitters.
Topics: Humans; Sleep Apnea Syndromes; Sleep Apnea, Obstructive; Respiration; Sleep; gamma-Aminobutyric Acid
PubMed: 36976413
DOI: 10.1007/s11325-023-02783-7 -
CMAJ : Canadian Medical Association... Jan 2024
Topics: Humans; Narcolepsy
PubMed: 38228341
DOI: 10.1503/cmaj.230650 -
Journal of Evidence-based Medicine Dec 2023Observational studies had demonstrated a link between sleep disturbances and cognitive decline. Here, we aimed to investigate the causal association between genetically...
OBJECTIVE
Observational studies had demonstrated a link between sleep disturbances and cognitive decline. Here, we aimed to investigate the causal association between genetically predicted sleep traits and cognitive impairment using Mendelian randomization (MR).
METHODS
Using strict criteria, we selected genetic variants from European ancestry Genome-wide association studies (GWAS) from the Sleep Disorders Knowledge Portal and UK Biobank as instrumental variables for several sleep traits, including insomnia, sleep duration, daytime sleepiness, daytime napping, and chronotype. Summary statistics related to cognitive impairment were derived from five different GWAS, including the Social Science Genetic Association Consortium. The role of self-reported sleep trait phenotypes in the etiology of cognitive impairment was explored using inverse-variance weighted (IVW) tests, MR-Egger tests, and weighted medians, and sensitivity analyses were conducted to ensure robustness.
RESULTS
In the main IVW analysis, sleep duration (reaction time: β = -0.05, 95% CI -0.07 to -0.04, p = 1.93×10 ), daytime sleepiness (average cortical thickness: β = -0.12, 95% CI -0.22 to -0.02, p = 0.023), and daytime napping (fluid intelligence: β = -0.47, 95% CI -0.87 to -0.07, p = 0.021; hippocampal volume in Alzheimer's disease: β = -0.99, 95% CI -1.64 to -0.35, p = 0.002) were significantly negatively correlated with cognitive performance. However, any effects of insomnia and chronotype on cognitive impairment were not determined.
CONCLUSIONS
Our findings highlighted that focusing on sleep behaviors or distinct sleep patterns-particularly sleep duration, daytime sleepiness, and daytime napping, was a promising approach for preventing cognitive impairment. This study also shed light on risk factors for and potential early markers of cognitive impairment risk factors.
Topics: Humans; Sleep Initiation and Maintenance Disorders; Genome-Wide Association Study; Mendelian Randomization Analysis; Sleep; Cognitive Dysfunction; Phenotype; Disorders of Excessive Somnolence
PubMed: 38108111
DOI: 10.1111/jebm.12576 -
Continuum (Minneapolis, Minn.) Aug 2023The goals of this article are to describe the clinical approach to and management of patients with central disorders of hypersomnolence, and to understand and...
OBJECTIVE
The goals of this article are to describe the clinical approach to and management of patients with central disorders of hypersomnolence, and to understand and differentiate available diagnostic tools.
LATEST DEVELOPMENTS
Updated clinical practice guidelines for the treatment of central disorders of hypersomnolence and narcolepsy specifically highlight new treatment options. Approval for a lower-sodium oxybate formulation that contains 92% less sodium than the standard sodium oxybate for the treatment of narcolepsy and idiopathic hypersomnia adds to the number of medications available for these disorders, allowing for a more tailored management of symptoms.
ESSENTIAL POINTS
Central disorders of hypersomnolence are characterized by excessive daytime sleepiness that impacts daily functions. These disorders can be differentiated by obtaining a detailed clinical sleep history and by a thoughtful interpretation of sleep diagnostic testing. Tailoring treatment approaches to meet the needs of individuals and accounting for medical and psychiatric comorbidities may improve quality of life.
Topics: Humans; Quality of Life; Sodium Oxybate; Disorders of Excessive Somnolence; Narcolepsy; Sleep
PubMed: 37590822
DOI: 10.1212/CON.0000000000001265 -
The Lancet. Respiratory Medicine Feb 2024In patients with heart failure and reduced ejection fraction, sleep-disordered breathing, comprising obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is... (Randomized Controlled Trial)
Randomized Controlled Trial
Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial.
BACKGROUND
In patients with heart failure and reduced ejection fraction, sleep-disordered breathing, comprising obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is associated with increased morbidity, mortality, and sleep disruption. We hypothesised that treating sleep-disordered breathing with a peak-flow triggered adaptive servo-ventilation (ASV) device would improve cardiovascular outcomes in patients with heart failure and reduced ejection fraction.
METHODS
We conducted a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial of peak-flow triggered ASV in patients aged 18 years or older with heart failure and reduced ejection fraction (left ventricular ejection fraction ≤45%) who were stabilised on optimal medical therapy with co-existing sleep-disordered breathing (apnoea-hypopnoea index [AHI] ≥15 events/h of sleep), with concealed allocation and blinded outcome assessments. The trial was carried out at 49 hospitals in nine countries. Sleep-disordered breathing was stratified into predominantly OSA with an Epworth Sleepiness Scale score of 10 or lower or predominantly CSA. Participants were randomly assigned to standard optimal treatment alone or standard optimal treatment with the addition of ASV (1:1), stratified by study site and sleep apnoea type (ie, CSA or OSA), with permuted blocks of sizes 4 and 6 in random order. Clinical evaluations were performed and Minnesota Living with Heart Failure Questionnaire, Epworth Sleepiness Scale, and New York Heart Association class were assessed at months 1, 3, and 6 following randomisation and every 6 months thereafter to a maximum of 5 years. The primary endpoint was the cumulative incidence of the composite of all-cause mortality, first admission to hospital for a cardiovascular reason, new onset atrial fibrillation or flutter, and delivery of an appropriate cardioverter-defibrillator shock. All-cause mortality was a secondary endpoint. Analysis for the primary outcome was done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT01128816) and the International Standard Randomised Controlled Trial Number Register (ISRCTN67500535), and the trial is complete.
FINDINGS
The first and last enrolments were Sept 22, 2010, and March 20, 2021. Enrolments terminated prematurely due to COVID-19-related restrictions. 1127 patients were screened, of whom 731 (65%) patients were randomly assigned to receive standard care (n=375; mean AHI 42·8 events per h of sleep [SD 20·9]) or standard care plus ASV (n=356; 43·3 events per h of sleep [20·5]). Follow-up of all patients ended at the latest on June 15, 2021, when the trial was terminated prematurely due to a recall of the ASV device due to potential disintegration of the motor sound-abatement material. Over the course of the trial, 41 (6%) of participants withdrew consent and 34 (5%) were lost to follow-up. In the ASV group, the mean AHI decreased to 2·8-3·7 events per h over the course of the trial, with associated improvements in sleep quality assessed 1 month following randomisation. Over a mean follow-up period of 3·6 years (SD 1·6), ASV had no effect on the primary composite outcome (180 events in the control group vs 166 in the ASV group; hazard ratio [HR] 0·95, 95% CI 0·77-1·18; p=0·67) or the secondary endpoint of all-cause mortality (88 deaths in the control group vs. 76 in the ASV group; 0·89, 0·66-1·21; p=0·47). For patients with OSA, the HR for all-cause mortality was 1·00 (0·68-1·46; p=0·98) and for CSA was 0·74 (0·44-1·23; p=0·25). No safety issue related to ASV use was identified.
INTERPRETATION
In patients with heart failure and reduced ejection fraction and sleep-disordered breathing, ASV had no effect on the primary composite outcome or mortality but eliminated sleep-disordered breathing safely.
FUNDING
Canadian Institutes of Health Research and Philips RS North America.
Topics: Humans; Stroke Volume; Sleepiness; Ventricular Function, Left; Canada; Sleep Apnea Syndromes; Heart Failure; Sleep Apnea, Central; Sleep Apnea, Obstructive; Treatment Outcome
PubMed: 38142697
DOI: 10.1016/S2213-2600(23)00374-0 -
Continuum (Minneapolis, Minn.) Aug 2023Obstructive sleep apnea (OSA) is the most common type of sleep-disordered breathing. This article describes advances in the diagnosis, testing, treatment, and monitoring...
OBJECTIVE
Obstructive sleep apnea (OSA) is the most common type of sleep-disordered breathing. This article describes advances in the diagnosis, testing, treatment, and monitoring of OSA.
LATEST DEVELOPMENTS
Home sleep apnea testing and in-laboratory polysomnography are the most commonly used diagnostic tools in the identification and monitoring of OSA, but new methods for diagnosis and at-home monitoring of treatment response are being developed and validated. While the apnea-hypopnea index is regularly used to define OSA severity, recognition is increasing of its inability to risk-stratify patients. Other sleep study data including arousal threshold, hypoxic burden, and pulse rate variability as well as clinical characteristics can help with risk stratification. The most effective treatment is continuous positive airway pressure (CPAP), which can be limited by adherence and tolerance in some patients. Newer masks and comfort features including heated tubing and expiratory pressure relief may improve tolerance to positive airway pressure (PAP) therapy. Additional treatment options include other PAP modalities, mandibular advancement devices, tongue stimulation therapy, negative inspiratory pressure, nasal expiratory pressure valves, nasal congestion treatments, upper airway surgeries including hypoglossal nerve stimulation, and medications.
ESSENTIAL POINTS
OSA is a common disorder that causes sleep and daytime symptoms and increases the risk of neurologic and medical complications. Neurologists should be aware of atypical presentations and understand the diagnostic and treatment options.
Topics: Humans; Sleep Apnea, Obstructive; Sleep Apnea Syndromes; Sleep; Hot Temperature
PubMed: 37590823
DOI: 10.1212/CON.0000000000001264 -
Sleep Medicine Clinics Dec 2023Postmenopause is defined retrospectively after 12 consecutive months of amenorrhea. It represents the end of the reproductive period and ovarian failure. A decrease in... (Review)
Review
Postmenopause is defined retrospectively after 12 consecutive months of amenorrhea. It represents the end of the reproductive period and ovarian failure. A decrease in estrogen leads to several changes in the short and long term. Among the early changes, vasomotor symptoms (hot flashes) are particularly common, occurring in about 70% of women. In addition, there are changes in mood, anxiety, depression, and insomnia. Insomnia occurs in almost 60% of postmenopausal women. Psychosocial aspects may also affect sleep. Proper diagnosis may lead to adequate treatment of sleep disturbances during menopause. Hormonal or other complementary therapies can improve sleep quality.
Topics: Female; Humans; Sleep Initiation and Maintenance Disorders; Retrospective Studies; Menopause; Sleep; Postmenopause
PubMed: 38501515
DOI: 10.1016/j.jsmc.2023.06.004