Sleep apnoea in memory clinic patients – an untapped opportunity to improve brain health 

Motif

Supervisors

  • Dr Liz Coulthard – Associate Professor in Dementia Neurology, Bristol Medical School
  • Nick Turner – Research Fellow in Medical Statistics
  • Dr Julie Clayton – Senior Research Associate in Patient and Public Involvement, Bristol Medical School 

Collaborators

  • Dr Gregor Russell – Consultant Old Age Psychiatrist with Bradford District Care NHS Foundation Trust
  • Dr David Woodstoke – Clinical Psychologist and Research Associate in the ReMemBr group
  • Victoria Gabb – Research Associate leading sleep studies in the ReMemBr group
  • Dr Sam Harding – Health Psychologist with qualitative expertise in North Bristol NHS Trust

Theme

Mental health

Keywords

Sleep, Alzheimer’s disease, sleep apnoea, co-production 

Background

Poor sleep speeds up progression of dementia and worsens quality of life in people with Alzheimer’s disease. Obstructive Sleep Apnoea is a common treatable condition where breathing is interrupted during sleep due to closure of the upper airways despite respiratory effort. Sleep apnoea increases the risk of cognitive impairment, dementia, heart disease and stroke.  

Sleep apnoea is common – published estimates of sleep apnoea prevalence in memory clinics range from 11-91%, and preliminary findings from the first 13 participants in our own clinic study using overnight oximetry suggest 8/13 had sleep apnoea and 2/13 had equivocal results (only 3/13 unequivocally did not have sleep apnoea). NICE-recommended screening questionnaires did not reliably detect sleep apnoea (lack of correlation between sleep apnoea score and Epworth Sleepiness Scale r2 = 0.09, p=0.33, STOP-BANG r2=0.003, p=0.87), suggesting a need for additional screening measures in this patient population.  

Treating sleep apnoea potentially improves cognition and quality of life. Typically patients are offered non-invasive ventilation, but many (>50%) cannot easily comply with treatment. Other treatments include mandibular advancement devices, but they are not routinely used. To treat sleep apnoea in memory clinic patients, we need to better understand what factors affect treatment tolerability and how this could be improved for everyone. 

There is an urgent need to identify and treat sleep apnoea in older people at risk of or with dementia. This project builds towards this goal, bringing direct clinical benefit. 

Aims and objectives

  1. To determine the prevalence of sleep apnoea in our memory clinic population
    We already have a study, DREAMS-AD (ethics approved), where we ask for consent to use all clinical data (131 participants recruited over 11 months, with a planned further 5 years of recruitment). Aims 1 and 2 will be a sub-study added onto DREAMS-AD in the same participants making the project feasible as i) >90% of the patients we approached agreed to DREAMS AD, ii) so far we only approached new clinic patients for DREAMS AD and plan to start approaching the follow up patients too, increasing the possible recruits to >800 over year, iii) PPI tells us that oximetry at home is acceptable to patients and, iv) In RESTED only 1 person approached has declined to have oximetry and that was due to new medical illness. Therefore, we expect to easily meet the 200 participants over 2-year recruitment target.
  2. To determine the best way to screen in clinic for sleep apnoea in memory clinic patients. Our eventual aim is to offer streamlined symptomatic or questionnaire-based screening in clinic, performing home monitoring with oximetry only when required.
  3. To understand the barriers and facilitators to use of non-invasive ventilation in memory clinic patients across a range of people from different backgrounds.

For aims three and four, we will use the links in Bristol and Bradford to include groups often not represented in research – including socioeconomically disadvantaged people and people from Somali and South Asian communities in the UK.

Methods

Aims 1 & 2 (Year 2 and 3) – The student will recruit 200 Participants from our NHS Cognitive Service over 2 years into a new substudy of DREAMS-AD where participants will be asked for consent for home overnight oximetry for 2 nights. The student will use Oxygen Desaturation Index to detect sleep apnoea using established cut-offs and determine the rates of mild, moderate and severe sleep apnoea in our memory clinic population. Using the clinical data acquired routinely, the student will also apply statistical models to work out which symptoms and scores on routine clinical questionnaires best predict sleep apnoea in our cohort. 

Aim 3 (Years 2-4) – Guided by Patient and Public Involvement, the student will develop and implement a semi-structured questionnaire and carry out two focus groups in people diagnosed with sleep apnoea who do and do not tolerate the treatment (non-invasive ventilation) (and their carers/loved ones) to determine the factors that help or hinder adherence to the device. From the start, the student will devote time to community engagement to build the relationships and interest in the topic and learn/train in co-production methods – to help produce the questionnaire and to explore how learning from the questionnaire could lead to co-production of a future sleep apnoea treatment package (as part of post-doctoral research training).  

Expected knowledge, skills and attitudes to be gained

The trainee will be given project-specific supervision including weekly meetings with the primary supervisor and at least monthly meetings with all supervisors. They will join a vibrant research group – the multidisciplinary ReMembr group – with fortnightly lab meetings and regular smaller team meetings for each project. The trainee will do Good Clinical Practice and in-house training to enable participants recruitment, consent and testing. 

Patient and public involvement and community engagement is at the heart of what we do and the candidate will develop PPI and engagement knowledge and experience supervised by Julie Clayton, capitalising on Julie’s close links to Bristol-based Somali and South Asian Communities and the demographic profile of patients in Bradford where we have PPI links with a population with a large number of people of South Asian heritage. The PhD student will be able to join and learn from a growing national Community of Practice network of Early Career Researchers building skills and knowledge around PPI in multi-morbidity, which Julie is co-leading on behalf of the University of Bristol, in collaboration with University of Birmingham. The PhD student will undertake training in PPI and co-production, in order to embed a PPI and co-production strategy throughout their PhD training. This will equip the student to be able to build relationships and understand community perspectives, barriers and facilitators to participating in clinical research. 

We will work with the student to develop study-specific and generic skills and knowledge by establishing a bespoke package of Bristol short courses to develop their methodological expertise, and supervision from Nick Turner. The student will be offered a training period in the Bristol Sleep and/or neurophysiology specialist sleep services. The candidate will also be encouraged to present their data at national and international conferences and will be supervised to write manuscripts to disseminate their findings. 

This project would suit students with physiology, neuroscience, psychology or medical qualifications and experience. 

References

  1. Osorio RS, Martínez-García MÁ, Rapoport DM. Sleep apnoea in the elderly: a great challenge for the future. Eur Respir J. 2021 Sep 24;59(4):2101649. doi: 10.1183/13993003.01649-2021. PMID: 34561285; PMCID: PMC8942873.
  2. Lal C, Ayappa I, Ayas N, Beaudin AE, Hoyos C, Kushida CA, Kaminska M, Mullins A, Naismith SL, Osorio RS, Phillips CL, Parekh A, Stone KL, Turner AD, Varga AW. The Link between Obstructive Sleep Apnea and Neurocognitive Impairment: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2022 Aug;19(8):1245-1256. doi: 10.1513/AnnalsATS.202205-380ST. PMID: 35913462; PMCID: PMC9353960.
  3. Bubu OM, Andrade AG, Umasabor-Bubu OQ, Hogan MM, Turner AD, de Leon MJ, Ogedegbe G, Ayappa I, Jean-Louis G G, Jackson ML, Varga AW, Osorio RS. Obstructive sleep apnea, cognition and Alzheimer’s disease: A systematic review integrating three decades of multidisciplinary research. Sleep Med Rev. 2020 Apr;50:101250. doi: 10.1016/j.smrv.2019.101250. Epub 2019 Dec 12. PMID: 31881487; PMCID: PMC7593825.