[Show abstract][Hide abstract] ABSTRACT: Clinical assessment and management of sleep disturbances in patients with mild cognitive impairment and dementia has important clinical and social implications. Poor sleep results in an increased risk of morbidities and mortality in demented patients and is a source of stress for caregivers. Sleep disturbances show high prevalence in mild cognitive impairment and dementia patients and they are often associated one to another in the same patient. A careful clinical evaluation of sleep disorders should be performed routinely in the clinical setting of individuals with cognitive decline. The Sleep Study Group of the Italian Dementia Research Association (SINDem) reviewed evidence from original research articles, meta-analyses and systematic reviews published up to December 2013. The evidence was classified in quality levels (I, II, III) and strength of recommendations (A, B, C, D, E). Where there was a lack of evidence, but clear consensus, good practice points were provided. These recommendations may not be appropriate for all circumstances and should therefore be adopted only after a patient's individual characteristics have been carefully evaluated.
[Show abstract][Hide abstract] ABSTRACT: In Parkinson's disease (PD) patients, REM sleep behavior disorder (RBD) might precede PD or develop with or after the onset of PD. No previous study has explored differences between these two groups. The aim of this study was therefore to compare clinical features and REM sleep chin electromyographic patterns between patients in whom RBD heralded PD and those in whom RBD occurrence coincided with or followed the clinical manifestations of PD.
Twenty-seven consecutive PD patients (mean age 67.9 years) were enrolled. Detailed clinical, laboratory, and polysomnographic studies were obtained in all participants.
Sixteen of the 27 patients were affected by RBD. These had a significantly higher stage of PD and took significantly higher doses of dopaminergic therapy; their disease duration tended to be longer, and their cognitive status tended to be lower. PD patients in whom RBD preceded PD (n = 6) did not differ from PD patients without RBD in disease parameters, while PD patients in whom RBD developed with or after PD (n = 10) showed a significantly higher disease stage, took significantly higher dopaminergic therapy, and had a longer disease duration.
Our findings are compatible with the hypothesis that patients in whom RBD precedes, or does not precede, PD might constitute two possibly distinct clinical and physiopathological groups, based on different progressive neuropathological sequences of events.
[Show abstract][Hide abstract] ABSTRACT: A patient is reported in whom signs and symptoms of REM sleep behavior disorder (RBD) and narcolepsy have been associated for almost two decades with a late development of parkinsonism and rheumatoid arthritis. A 78-year-old male patient in whom RBD was first diagnosed was followed-up by clinical examination, videopolysomnography, multiple sleep latency test, cerebral magnetic resonance imaging, and dopamine transporter imaging by single-photon emission computerized tomography. The patient was found to present for almost two decades, in addition to RBD, also narcolepsy. Moreover, a late development of parkinsonism and the occurrence of rheumatoid arthritis were detected and clinically and instrumentally characterized. Patients predisposed to RBD and later parkinsonism might be susceptible to a variety of triggers that, in our patient, might have been represented by a possible latent autoimmune process leading to the development of narcolepsy with cataplexy and rheumatoid arthritis, later.
[Show abstract][Hide abstract] ABSTRACT: Cortical sources of resting state electroencephalographic (EEG) rhythms are abnormal in subjects with Alzheimer's disease (AD). Here we tested the hypothesis that these sources are also sensitive to the progression of early stage AD over the course of one year. The resting state eyes-closed EEG data were recorded in 88 mild AD patients at baseline (Mini Mental State Evaluation, MMSE I = 21.7 ± 0.2 standard error, SE) and at approximately one-year follow up (13.3 months ± 0.5 SE; MMSE II = 20 ± 0.4 SE). All patients received standard therapy with acetylcholinesterase inhibitors. EEG recordings were also performed in 35 normal elderly (Nold) subjects as controls. EEG rhythms of interest were delta (2-4 Hz), theta (4-8 Hz), alpha 1 (8-10.5 Hz), alpha 2 (10.5-13 Hz), beta 1 (13-20 Hz), beta 2 (20-30 Hz), and gamma (30-40 Hz). Cortical EEG sources were estimated by low-resolution brain electromagnetic tomography (LORETA). Compared to the Nold subjects, the mild AD patients were characterized by a power increase of widespread delta sources and by a power decrease of posterior alpha sources. In the mild AD patients, the follow-up EEG recordings showed increased power of widespread delta sources as well as decreased power of widespread alpha and posterior beta 1 sources. These results suggest that the resting state EEG sources were sensitive, at least at group level, to the cognitive decline occurring in the mild AD group over a one-year period, and might represent cost-effective and non-invasive markers with which to enrich cohorts of AD patients that decline faster for clinical studies.
Journal of Alzheimer's disease: JAD 01/2013; · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To analyze the night-to-night variability of REM sleep electromyographic (EMG) features of REM sleep behavior disorder (RBD) by using the automatic quantitative method known as atonia index (AI), and to evaluate the improvement in sensitivity and specificity of AI for the diagnosis of RBD when a second recording night is available.
Sleep research center.
A group of 17 idiopathic RBD patients was recruited for whom 2 all-night polysomnographic (PSG) recordings were available. Thirty normal controls were also recruited and subgrouped into Young (< 45 years of age) or Aged (> 45 years). Chin EMG analysis was run on all recordings; night-to-night variability of both AI and number of chin EMG activations/h during REM sleep was additionally quantified as the absolute difference between the 2 nights standardized as the percentage of their mean.
Night-to-night variability of AI was higher in RBD patients (19.7%) than in the 2 groups of controls (Young 1.8% and Aged 2.8%). The values of variability of chin EMG activations were much higher than those of AI, especially in the Aged controls. Sensitivity of AI ≤ 0.9 for RBD was always higher than 82% and reached 88.9% for the combined-night analysis; specificity was also high, with a value of 92.3% for the combined-value analysis.
The night-to-night variability of AI seems to be very low in normal controls and remains under 20% in RBD patients; that of the number of EMG activations is higher. However, even a single PSG recording provides high values of sensitivity and specificity when a threshold value of AI ≤ 0.9 is used to define abnormal chin EMG levels during REM sleep that increase only moderately when a second night recording is available.
Ferri R; Marelli S; Cosentino FII; Rundo F; Ferini-Strambi L; Zucconi M. Night-to-night variability of automatic quantitative parameters of the chin EMG amplitude (atonia index) in REM sleep behavior disorder. J Clin Sleep Med 2013;9(3):253-258.
Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 01/2013; 9(3):253-258. · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We investigated nocturnal sleep abnormalities in 19 patients with idiopathic hypersomnia without long sleep time (IH) in comparison with two age- and sex- matched control groups of 13 normal subjects (C) and of 17 patients with narcolepsy with cataplexy (NC), the latter considered as the extreme of excessive daytime sleepiness (EDS). Sleep macro- and micro- (i.e. cyclic alternating pattern, CAP) structure as well as quantitative analysis of EEG, of periodic leg movements during sleep (PLMS), and of muscle tone during REM sleep were compared across groups. IH and NC patients slept more than C subjects, but IH showed the highest levels of sleep fragmentation (e.g. awakenings), associated with a CAP rate higher than NC during lighter sleep stages and lower than C during slow wave sleep respectively, and with the highest relative amount of A3 and the lowest of A1 subtypes. IH showed a delta power in between C and NC groups, whereas muscle tone and PLMS had normal characteristics. A peculiar profile of microstructural sleep abnormalities may contribute to sleep fragmentation and, possibly, EDS in IH.
Journal of Sleep Research 10/2012; · 3.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare REM sleep chin EMG quantitative features between Parkinson's disease (PD) patients with or without REM sleep behavior disorder (RBD).
Twenty-seven consecutive PD patients (mean age 67.9 years) and 19 normal controls (mean age 67.5 years) were enrolled. Detailed clinical, laboratory, and polysomnographic studies were obtained in all participants and characteristics of chin electromyographic amplitude during rapid eye movements sleep were analyzed by means of an automatic quantitative approach (Atonia Index).
Sixteen of the 27 patients were affected by RBD. An Atonia Index below 0.90 showed high sensitivity (0.938) and specificity (0.909) for the diagnosis of RBD within the group of PD patients.
This study recommends the Atonia Index as an objective measure to support and aid the diagnosis of RBD in PD.
Sleep Medicine 03/2012; 13(6):707-13. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Approximately one third of patients with restless legs syndrome (RLS) also show periodic leg movements (PLM) during relaxed wake fulness (PLMW). In contrast with the large amount of data published on periodic leg movements during sleep (PLMS), PLMW have received less attention from the scientific community. The objective of this study was to evaluate the correlations/differences of time-structure and response to a dopamine-agonist between PLMW and PLMS in patients with RLS.
Ninety idiopathic RLS patients and 28 controls were recruited. Subjects underwent clinical and neurophysiological evaluation, hematological screening, and one or two consecutive full-night polysomnographic studies. A subset of patients received 0.25mg of pramipexole or placebo before the second recording. Polysomnographic recordings were scored and LM activity was analyzed during sleep and during the epochs of wakefulness occurring during the first recording hour.
RLS patients had higher LM activity during wakefulness than controls, but with a similar periodicity. Even if correlated, the ability of the PLMW index to predict the PLMS index decreased with increasing LM activity. Intermovement intervals during wakefulness showed one peak only at approximately 4s, gradually decreasing with increasing interval in both patients and controls. The effect of pramipexole was very limited and involved the small periodic portion of LM activity during wakefulness.
PLMW index and PLMS index were correlated; however, the magnitude of this correlation was not sufficient to suggest that PLMW can be good predictors of PLMS. Short-interval LM activity during wakefulness and sleep might be linked to the severity of sleep disruption in RLS patients and the differences between their features obtained during wakefulness or sleep might be relevant for the diagnosis of sleep disturbances in RLS.
Sleep Medicine 02/2012; 13(5):529-35. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/Aims: Sleep disturbances are common in the elderly and in persons with cognitive decline. The aim of this study was to describe frequency and characteristics of insomnia, excessive daytime sleepiness, sleep-disordered breathing, REM behavior disorder and restless legs syndrome in a large cohort of persons with mild cognitive impairment or dementia. Methods: 431 consecutive patients were enrolled in 10 Italian neurological centers: 204 had Alzheimer's disease, 138 mild cognitive impairment, 43 vascular dementia, 25 frontotemporal dementia and 21 Lewy body dementia or Parkinson's disease dementia. Sleep disorders were investigated with a battery of standardized questions and questionnaires. Results: Over 60% of persons had one or more sleep disturbances almost invariably associated one to another without any evident and specific pattern of co-occurrence. Persons with Alzheimer's disease and those with mild cognitive impairment had the same frequency of any sleep disorder. Sleep-disordered breathing was more frequent in vascular dementia. REM behavior disorder was more represented in Lewy body or Parkinson's disease dementia. Conclusion: A careful clinical evaluation of sleep disorders should be performed routinely in the clinical setting of persons with cognitive decline. Instrumental supports should be used only in selected patients
[Show abstract][Hide abstract] ABSTRACT: Transforming growth factor-β1 (TGF-β1) is a neurotrophic factor that exerts neuroprotective effects against β-amyloid-induced neurodegeneration. Recently, a specific impairment of the TGF-β1 signaling pathway has been demonstrated in Alzheimer's disease (AD) brain. TGF-β1 is also involved in the pathogenesis of depressive disorders, which may occur in 30-40% of AD patients. The TGF-β1 gene contains single nucleotide polymorphisms (SNPs) at codon +10 (T/C) and +25 (G/C), which are known to influence the level of expression of TGF-β1. We investigated TGF-β1 +10 (T/C) and +25 (G/C) SNPs and allele frequencies in 131 sporadic AD patients and in 135 healthy age- and sex-matched controls. Genotypes of the TGF-β1 SNPs at codon +10 (T/C) and +25 (G/C) did not differ between AD patients and controls, whereas the allele frequencies of codon +10 polymorphism showed a significant difference (P = 0.0306). We also found a different distribution of the +10 (C/C) phenotype (continuity-corrected χ(2) test with one degree of freedom = 4.460, P = 0.0347) between late onset AD (LOAD) patients and controls (P = 0.0126), but not between early onset AD (EOAD) patients and controls. In addition, the presence of the C/C genotype increased the risk of LOAD regardless of the status of apolipoprotein E4 (odds ratio [OR] = 2.34; 95% CI = 1.19-4.59). Compared to patients bearing the T/T and C/T polymorphisms, LOAD TGF-β1 C/C carriers also showed > 5-fold risk to develop depressive symptoms independently of a history of depression (OR = 5.50; 95% CI = 1.33-22.69). An association was also found between the TGF-β1 C/C genotype and the severity of depressive symptoms (HAM-D(17) ≥ 14) (P < 0.05). These results suggest that the CC genotype of the TGF-β1 gene increases the risk to develop LOAD and is also associated with depressive symptoms in AD.
European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology 09/2011; 22(4):281-9. · 3.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Restless legs syndrome (RLS) might represent a condition at risk of cardiovascular (and cerebrovascular) disease; the role of sleep periodic leg movements, sleep deprivation, and presence of common risk factors for heart disease in these patients remains to be determined. The aim of this study was to evaluate the eventual presence of risk factors for cerebrovascular disease in RLS.
Eighty-seven consecutive patients affected by idiopathic RLS were included in this study together with 81 controls. Blood count, chemistry, and kidney function tests were obtained. We detected subjects suffering from diabetes mellitus, kidney diseases, heart diseases, disk herniation, neuropathy, blood diseases, liver diseases, artery diseases, dyslipidemia, or hypertension. Polysomnography was recorded in 66 patients, and cerebral neuroimaging was obtained in 59 patients with RLS.
None of the differences in blood test parameters was statistically significant; however, hypertension was found to be more frequent in controls and dyslipidemia was more frequent in patients with RLS, but this was explained by its higher frequency in patients also affected by obstructive sleep apnea. A diagnosis of cerebrovascular disease was posed for 14 patients with RLS (16.1%), but no predictive factor for its presence was found at the binomial logistic regression.
Our findings argue against the presence of an altered lipid metabolism as a risk factor for the development of cerebrovascular disease in patients with RLS, even if they do support the idea that cerebrovascular disease might be frequent in this condition.
[Show abstract][Hide abstract] ABSTRACT: Resting state electroencephalographic (EEG) rhythms do not deteriorate with the increase of white matter vascular lesion in amnesic mild cognitive impairment (MCI) subjects , although white matter is impaired along Alzheimer's disease (AD). Here we tested whether this is true even in AD subjects. Closed-eye resting state EEG data were recorded in 40 healthy elderly (Nold), 96 amnesic MCI, and 83 AD subjects. White matter vascular lesions were indexed by magnetic resonance imaging recorded in the MCI and AD subjects (about 42% of cases following ADNI standards). The MCI subjects were divided into two sub-groups based on the median of the white matter lesion, namely MCI+ (people with highest vascular load; n = 48) and MCI- (people with lowest vascular load; n = 48). The same was true for the AD subjects (AD+, n = 42; AD-, n = 41). EEG rhythms of interest were delta (2-4 Hz), theta (4-8 Hz), alpha1 (8-10.5 Hz), alpha2 (10.5-13 Hz), beta1 (13-20 Hz), beta2 (20-30 Hz), and gamma (30-40 Hz). LORETA software estimated cortical EEG sources. When compared to Nold group, MCI and AD groups showed well known abnormalities of delta and alpha sources. Furthermore, amplitude of occipital, temporal, and limbic alpha 1 sources were higher in MCI+ than MCI- group. As a novelty, amplitude of occipital delta sources was lower in AD+ than AD- group. Furthermore, central, parietal, occipital, temporal, and limbic alpha sources were higher in amplitude in AD+ than AD- group. Amplitude of these sources was correlated to global cognitive status (i.e., Mini Mental State Evaluation score). These results suggest that in amnesic MCI and AD subjects, resting state posterior delta and alpha EEG rhythms do not deteriorate with the increase of white-matter vascular lesion. These rhythms might be more sensitive to AD neurodegenerative processes and cognitive status rather than to concomitant lesions to white matter.
[Show abstract][Hide abstract] ABSTRACT: To investigate the occurrence of restless legs syndrome (RLS) in narcolepsy with cataplexy (NC).
A case-control study assessing the frequency of comorbidity of RLS and NC in three European sleep disorder centers.
Three sleep research centers recruited 184 NC patients and 235 age-matched controls.
NC patients and controls underwent a face-to-face interview investigating demographics, medical and drug history, sleep habits, and sleep disorders, in particular RLS based on the 4 international criteria and on a frequency > or =2 times/week, with a detailed description of RLS symptoms when present. RLS was significantly more prevalent among NC patients (14.7%) than in controls (3.0%). The age at onset of RLS in NC patients fits with the age at onset in idiopathic RLS, and RLS appeared more than 10 years after NC onset. Unlike idiopathic RLS, RLS in NC subjects was not more prevalent in women and was less familial (15.4% of cases). Lastly, NC patients with RLS showed a moderate disease severity and an almost daily occurrence of symptoms, which were also diurnal in 35% of cases. Older age, higher blood ferritin levels, and sleep paralysis seem to have a predictive value for RLS in NC. The higher ferritin levels indicate that different pathophysiological mechanisms underlie secondary RLS associated with NC.
This study highlights the association between RLS and NC. The nature of this association is still investigational, but it does indicate that RLS must be addressed in the evaluation and management of nocturnal sleep impairment in NC patients.
[Show abstract][Hide abstract] ABSTRACT: Wakefulness, rapid eye movement (REM) and non-REM sleep are not always mutually exclusive conditions, as commonly assumed. In some cases, the declaration of any state may be incomplete and states can fluctuate rapidly, resulting in peculiar behavioural syndromes such as narcolepsy, REM sleep behaviour disorder and status dissociatus. We briefly introduce this topic and discuss three suggestive clinical cases.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to detect the eventual presence of a minor voluntary motor involvement in restless legs syndrome (RLS), not detectable clinically, which might be observed by means of a sophisticated instrumental analysis of movement, such as gait analysis.
Gait analysis was performed and surface EMG activity was recorded in 13 RLS patients and 8 normal controls from 8 muscles: tibialis anterior, gastrocnemius lateralis, gastrocnemius medialis, and soleus in both legs.
Ten out of the 13 RLS patients and none of the normal control group showed a mild abnormality of the EMG activation of the gastrocnemius muscles during gait which, however, had no detectable effects on its kinematics.
These preliminary results might be interpreted as the effect of an impaired supraspinal dopaminergic control with possible action on spinal structures involved in the control of gait. If confirmed in future studies, this mild EMG abnormality might constitute an additional supportive feature for the diagnosis of RLS in difficult cases.
Sleep Medicine 09/2008; 10(3):312-6. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Contradictory data have been published on the influence of Apolipoprotein E (APOE) epsilon4 allele on obstructive sleep apnea (OSA). The aims of this study were to confirm the presence of specific neuropsychological changes in OSA patients carrying the APOE epsilon4 allele and to clarify if these changes are due to the sole presence of this allele or to its interactions with OSA pathology.
The APOE genotype was examined in 123 patients with OSA and in 121 controls, together with a series of neuropsychological tests.
OSA and control subjects had similar APOE genotype and allele distribution, but when neuropsychological tests were considered, OSA patients showed significantly lower values for verbal long-term (delayed free recall at the Rey auditory-verbal learning test) and working memory (bisyllabic words). Moreover, spatial span was found to be lower in OSA epsilon4 allele carriers than in non-carriers; this difference was not observed in controls.
This study confirms the presence of a verbal memory impairment in OSA patients and provides evidence for a significant interaction of APOE epsilon4 allele and OSA on frontal lobe function in adults, possibly mediated by the presence of specific frontal lobe neuroanatomical changes in these patients.
Sleep Medicine 01/2008; 9(8):831-9. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to evaluate and statistically describe the age-related changes in leg movements (LMs) during sleep in a large group of subjects with restless legs syndrome (RLS).
One hundred eight untreated patients affected by idiopathic RLS were included in this study (mean age 52.0years, min 7.5, max 83.2years). The time structure of their polysomnographically recorded LMs was analyzed using an approach particularly appropriate for assessing their quantity, periodicity, and distribution during the night.
Periodic LMs during sleep (PLMS) increased in number gradually in the age groups. Their typical interval was approximately 24-28s before the age of 55years but at approximately 14-16s after the age of 65years. PLMS index reached a plateau at 15-25years of age and remained stable up to 65years; after this age, it showed an important increase. Periodicity index (PI) increased progressively up to the age of 35years and then remained stable up to the age of 85years. No correlation was found between PLMS index and PI. The number of PLMS per hour of sleep declined through the night in subjects aged 15-75years; after this age, PLMS tended to be equally distributed across the entire night.
The use of three main parameters derived from the analysis of leg motor activity during sleep in RLS patients (PLMS index, PI and PLMS time distribution) is capable of providing us with important information about the age-related changes of PLMS in this condition, which can be used in the evaluation of the sleep motor patterns in these subjects.
Sleep Medicine 12/2007; 9(7):790-8. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purposes of this study were to validate the use of a single standard question for the rapid screening of restless legs syndrome (RLS) and to analyze the eventual effects of the presence of RLS on self-assessed daytime sleepiness, global clinical severity and cognitive functioning. We evaluated a group of 521 consecutive patients who accessed our neurology clinic for different reasons. Beside the answer to the single question and age, sex, and clinical diagnosis, the following items were collected from all patients and normal controls: the four criteria for RLS, the Epworth Sleepiness Scale (ESS), the Clinical Global Impression of Severity (CGI-S), and the Mini-Mental State evaluation. RLS was found in 112 patients (70 idiopathic). The single question had 100% sensitivity and 96.8% specificity for the diagnosis of RLS. ESS and CGI-S were significantly higher in both RLS patient groups than in normal controls. RLS severity was significantly higher in idiopathic than in associated/symptomatic RLS patients. RLS can be screened with high sensitivity and good reliability in large patient groups by means of the single question; however, the final diagnosis should always be confirmed by the diagnostic features of RLS and accompanied by a careful search for comorbid conditions.
European Journal of Neurology 10/2007; 14(9):1016-21. · 4.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several studies have demonstrated the importance of hypercholesterolemia as a cardiovascular risk factor and a direct correlation between the reduction in cholesterolemia and the reduction in cardiovascular mortality in populations younger than 65 years. This correlation is controversial in the elderly and, particularly, in the oldest old. The aim of our study was to evaluate the total cholesterol in the oldest old and to assess the eventual presence of correlation between total cholesterol levels and mortality in a group of nondemented oldest old. A subsample of 40 subjects was extracted from the 103 subjects aged over 84 years living in Troina, a rural village in Sicily. We excluded all subjects under therapy with lipid-lowering drugs, demented, with malnutrition or affected by acute or chronic diseases which might cause death in the short term. At the end, 23 subjects (15 males and 8 females) were included in the study. After 2 years, mortality data of all subjects included in the study were obtained from official registers. The statistical analysis was performed by means of the X(2) test. In all subjects the mean of total cholesterol was of 182+/-32 mg/dl (mean+/-SD) and the body mass index was above 20; 17 subjects were in the normal range, 3 were moderately over-weighed and 3 were severely over-weighed. Overall, mortality rate after 2 years was 30% (7 subjects, 4 males and 3 females). We evaluated the relationship between mortality and 4 factors: sex, age, body mass index (BMI) and serum total cholesterol. Mortality was significantly correlated (p<0.002) only with a low level of total serum cholesterol<or=160 mg/dl). Our data are in agreement with those already available in the literature, and demonstrate that in the oldest old levels of total cholesterol lower than those of young subjects are found, but when the total cholesterol decreases below a hypothetical critical limit of 160 mg/dl represent, an important index of frailty in the oldest old and a predictor of mortality.
Archives of Gerontology and Geriatrics 01/2007; 44 Suppl 1:381-4. · 1.70 Impact Factor