OSAS-Related Cognitive Impairment after First-Ever Stroke: Study Design and Methodology
DOI:
https://doi.org/10.12974/2309-6179.2017.05.07Keywords:
OSAS, neurocognitive impairment, stroke, CPAP.Abstract
Introduction: Obstructive Sleep Apnea Syndrome (OSAS) is considered an emerging risk factor for cerebrovascular disease. Both the two conditions could share the same neurocognitive impairment, which, in the early phase of OSAS, are reversible and mediated by the excessive daytime sleepiness. Treatment with continuous positive air pressure (CPAP) device could improve the neurocognitive functions, and therefore, it could be considered as a valid treatment option in stroke patients affected by OSAS and neurocognitive impairment.
Materials and Methods: Patients affected by unilateral ischemic stroke will be subdivided into two groups, according to the presence or absence of OSAS. All participants will be evaluated by using a specific neuropsychological battery exploring attention, memory, praxic abilities and executive functions. Patients presented with a moderate to severe OSAS will be treated with CPAP and followed for at least 1 year.
Results: The data analysis requires a sample size of 550 to provide adequate power of the study. The outcome variable is the score of specific neuropsychological and quality of life tests at baseline, after 6 months and at 1 year follow-up.
Discussion and Conclusion: This study design presents three specific analysis limitations. First, several other sleep disorders can produce drowsiness beyond OSAS. Second, the neurocognitive impairment in stroke patients is difficult to assess. Third, OSAS patients are often intolerant to diagnostic tests requiring an excessive length.
However, the findings coming from the protocol may have important implications about the effect of sleep disorders on cognitive function in stroke patients. Moreover, the easy employed procedures could be translated into clinical practice to improve the quality of life of patients affected by both OSAS and stroke.
References
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005; 353: 2034-41. https://doi.org/10.1056/NEJMoa043104
Malhotra A, Pillar G, Fogel RB, Edwards JK, Ayas N, et al. Pharyngeal pressure and flow effects on genioglossus activation in normal subjects. Am J Respir Crit Care Med. 2002; 165: 71-7. https://doi.org/10.1164/ajrccm.165.1.2011065
Fogel RB, Malhotra A, Pillar G, Edwards JK, Beauregard J, et al. Genioglossal activation in patients with obstructive sleep apnea versus control subjects. Mechanisms of muscle control. Am J Respir Crit Care Med. 2001; 164: 2025-30. https://doi.org/10.1164/ajrccm.164.11.2102048
Wheatley JR, Tangel DJ, Mezzanotte WS and White DP. Influence of sleep on response to negative airway pressure of tensor palatini muscle and retropalatal airway. J Appl Physiol. 1993; 75: 2117-24. https://doi.org/10.1152/jappl.1993.75.5.2117
Horner RL, Innes JA, Morrell MJ, Shea SA, Guz A. The effect of sleep on reflex genioglossus muscle activation by stimuli of negative airway pressure in humans. J Physiol 1994; 476: 141-51.
Kimoff RJ, Sforza E, Champagne V, Ofiara L and Gendron D. Upper airway sensation in snoring and obstructive sleep apnea. Am J Respir Crit Care Med 2001; 164: 250-5. https://doi.org/10.1164/ajrccm.164.2.2010012
Hudgel DW and Harasick T. Fluctuation in timing of upper airway and chest wall inspiratory muscle activity in obstructive sleep apnea. J Appl Physiol 1990; 69: 443-50. https://doi.org/10.1152/jappl.1990.69.2.443
Somers VK, Dyken ME, Clary MP and Abboud FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 1995; 96: 1897-904 https://doi.org/10.1172/JCI118235
Marti S, Sampol G, Mu-oz X, Torres F, Roca A, et al. Mortality in severe sleep apnoea/hypopnoea syndrome patients: impact of treatment. Eur Respir J 2002; 20: 1511-8 https://doi.org/10.1183/09031936.02.00306502
He J, Kryger MH, Zorick FJ, Conway W and Roth T. Mortality and apnea index in obstructive sleep apnea. Experience in 385 male patients. Chest 1988; 94: 9-14 https://doi.org/10.1378/chest.94.1.9
Gleeson K, Zwillich CW and White DP. The influence of increasing ventilatory effort on arousal from sleep. Am Rev Respir Dis 1990; 142: 295-300 https://doi.org/10.1164/ajrccm/142.2.295
Lindberg E, Carter N, Gislason T and Janson C. Role of snoring and daytime sleepiness in occupational accidents. Am J Respir Crit Care Med 2001; 164: 2031-5. https://doi.org/10.1164/ajrccm.164.11.2102028
Kim HC, Young T, Matthews CG, Weber SM, Woodward AR, et al. Sleep-disordered breathing and neuropsychological deficits. A population-based study. Am J Respir Crit Care Med 1997; 156: 1813-9. https://doi.org/10.1164/ajrccm.156.6.9610026
Redline S, Strauss ME, Adams N, Winters M, Roebuck T, et al. Neuropsychological function in mild sleep-disordered breathing. Sleep 1997; 20: 160-7. https://doi.org/10.1093/sleep/20.2.160
Harbison J, Gibson GJ, Birchall D, Zammit-Maempel I and Ford GA. White matter disease and sleep-disordered breathing after acute stroke. Neurology 2003; 61: 959-63. https://doi.org/10.1212/01.WNL.0000086818.57992.B8
Malhotra A and White DP. Obstructive sleep apnoea. Lancet 2002; 360: 237-45. https://doi.org/10.1016/S0140-6736(02)09464-3
Engleman HM, Kingshott RN, Wraith PK, Mackay TW, Deary IJ, et al. Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep Apnea/Hypopnea syndrome. Am J Respir Crit Care Med 1999; 159: 461-7. https://doi.org/10.1164/ajrccm.159.2.9803121
Jenkinson C, Stradling J and Petersen S. Comparison of three measures of quality of life outcome in the evaluation of continuous positive airways pressure therapy for sleep apnoea. J Sleep Res 1997; 6: 199-204. https://doi.org/10.1046/j.1365-2869.1997.00043.x
Yaggi H and Mohsenin V. Obstructive sleep apnoea and stroke. Lancet Neurol 2004; 3: 333-42. https://doi.org/10.1016/S1474-4422(04)00766-5
Bassetti C, Aldrich MS, Chervin RD and Quint D. Sleep apnea in patients with transient ischemic attack and stroke: a prospective study of 59 patients. Neurology 1996; 47: 1167- 73. https://doi.org/10.1212/WNL.47.5.1167
Bassetti C and Aldrich MS. Sleep apnea in acute cerebrovascular diseases: final report on 128 patients. Sleep 1999; 22: 217-23. https://doi.org/10.1093/sleep/22.2.217
Parra O, Arboix A, Bechich S, García-Eroles L, Montserrat JM, et al. Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Respir Crit Care Med 2000; 161: 375-80 https://doi.org/10.1164/ajrccm.161.2.9903139
Ferro JM. Hyperacute cognitive stroke syndromes. J Neurol 2001; 248: 841-9. https://doi.org/10.1007/s004150170067
Bassetti CL, Milanova M and Gugger M. Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome. Stroke 2006; 37: 967-72. https://doi.org/10.1161/01.STR.0000208215.49243.c3
Tosun A, KoÅNktürk O, Karata GK, Ciftçi TU and Sepici V. Obstructive sleep apnea in ischemic stroke patients. Clinics 2008; 63: 625-30. https://doi.org/10.1590/S1807-59322008000500010
Foster GE, Hanly PJ, Ostrowski M and Poulin MJ. Effects of continuous positive airway pressure on cerebral vascular response to hypoxia in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2007; 175: 720-5. https://doi.org/10.1164/rccm.200609-1271OC
Hsu CY, Vennelle M, Li HY, Engleman HM, Dennis MS, et al. Sleep-disordered breathing after stroke: a randomised controlled trial of continuous positive airway pressure. J Neurol Neurosurg Psychiatry 2006; 77: 1143-9. https://doi.org/10.1136/jnnp.2005.086686
Bamford J, Sandercock P, Dennis M, Burn J and Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337: 1521-6. https://doi.org/10.1016/0140-6736(91)93206-O
Luce RD. Response Times: Their Role in Inferring Elementary Mental Organization. Oxford University Press, New York 1986.
Giovagnoli AR, Del Pesce M, Mascheroni S, Simoncelli M, Laiacona M, et al. Trail making test: normative values from 287 normal adult controls. Ital J Neurol Sci 1996; 17: 305- 309. https://doi.org/10.1007/BF01997792
Berg EA. A simple objective technique for measuring flexibility in thinking. J Gen Psychol 1948; 39: 15-22. https://doi.org/10.1080/00221309.1948.9918159
Rey A. Memorisation d'une serie de 15 mots en 5 repetitions. In: Rey A (ed.) L'Examen Clinique en Psycologie. Presses Universitaires de France, Paris 1958.
Wechsler D. Wechsler memory scale-Revised Manual. San Antonio, TX: The Psychological Corporation 1987.
Spinnler H and Tognoni G. Standardizzazione e taratura italiana di test neuropsicologici. Ital J Neurol Sci 1987; 6(suppl 8).
Rey A. Reattivo della figura complessa. Manuale. Organizzazioni Speciali, Firenze 1983.
Caffarra P, Vezzadini G, Dieci F, Zonato F and Venneri A. Rey-Osterrieth complex figure: normative values in an Italian population sample. Neurol Sci 2002; 22:443-447. https://doi.org/10.1007/s100720200003
American Academy of Sleep Medicine Task Force. Sleeprelated breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep 1999; 22: 667-89. https://doi.org/10.1093/sleep/22.5.667
Young T, Peppard PE and Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165: 1217-39. https://doi.org/10.1164/rccm.2109080
