The Effect of OSA on Brain Waste Clearance

Dementia Clinical Trial

Official title:

The Impact of 2 Weeks CPAP Withdrawal on Brain Waste Clearance in Adults With Severe Obstructive Sleep Apnoea - A Randomised Controlled Crossover Trial

Clinical Trial Details — Status: Enrolling by invitation

Administrative data

• NCT number: NCT05606991
• Other study ID #: BrainOSA-0522
• Status: Enrolling by invitation
• Phase: N/A
• Start date: July 18, 2023
• Est. completion date: December 2024

Study information

• Verified date: December 2023
• Source: Woolcock Institute of Medical Research
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Recent ground-breaking research has shown that clearance of toxic neuro-metabolites from the brain including the proteins β-Amyloid (Aβ) and tau that form dementia causing plaques and tangles is markedly impaired when sleep is disturbed. This suggests that dementia risk may be increased in people with sleep disorders such as obstructive sleep apnea (OSA). Longitudinal studies have linked OSA with a 70-85% increased risk for mild cognitive impairment and dementia. Despite this strong link, little is known about the OSA-specific mechanistic underpinnings. It is not fully understood as to how sleep disturbance in OSA inhibit brain glymphatic clearance. However, it is known that OSA inhibits slow wave sleep, profoundly activates sympathetic activity, and elevates blood pressure - particularly during sleep. These disturbances have, in turn, been shown to independently inhibit glymphatic function. Previous studies have attempted to sample human cerebrospinal fluid (CSF) involved in glymphatic clearance for dementia biomarkers during sleep. However, these studies were severely limited by the need for invasive CSF sampling. To address this problem, a set of newly available, highly sensitive blood based SIMOA assays will be used to study glymphatic function in people treated for severe OSA who undergo CPAP withdrawal. Furthermore, novel methods will be utilized to capture changes in slow wave sleep, blood pressure and brain blood flow together with sleep-wake changes in blood levels of excreted neuro-metabolites to define the pathophysiological mechanisms that inhibit brain cleaning in OSA.

Description:

Dementia is a neurodegenerative disease characterized by cognitive dysfunction affecting aspects of memory and learning. Although the mechanisms that underlie the pathophysiology of dementia are still unclear, in the past decade there has been a focus on the adverse impact of sleep disturbance on brain waste disposal via the glymphatic system. The glymphatic system is a recently discovered brain-wide perivascular passageway that transports toxic neuro-metabolites (e.g.: amyloid beta, or Aβ) out of the brain to the blood via the cerebrospinal fluid. Newer research has shown that the glymphatic system becomes particularly active during sleep, clearing metabolites twice as fast compared with wakefulness. Obstructive sleep apnea (OSA), a sleep disorder characterized by periods of intermittent hypoxia and sleep fragmentation due to obstructed breathing, has traditionally been causatively linked to the development of hypertension and cognitive dysfunction. Further to this, recent epidemiological studies have also linked OSA to an increased risk for both dementia and its prodromal state - mild cognitive impairment. There is emerging evidence to suggest that OSA might chronically impair glymphatic clearance of Aβ42 from the brain and facilitate the formation of Aβ plaques that characterize Alzheimer's Disease. Recent ground-breaking research has shown that clearance of toxic neuro-metabolites from the brain including the proteins Aβ and tau that form dementia causing plaques and tangles is markedly impaired when sleep is disturbed. This suggests that dementia risk may be increased in people with sleep disorders such as OSA. Longitudinal studies have linked OSA with a 70-85% increased risk for mild cognitive impairment and dementia. Despite this strong link, little is known about the OSA-specific mechanistic underpinnings. It is not fully understood as to how sleep disturbance in OSA inhibit brain glymphatic clearance. However, it is known that OSA inhibits slow wave sleep, profoundly activates sympathetic activity, and elevates blood pressure - particularly during sleep. These disturbances have, in turn, been shown to independently inhibit glymphatic function. Previous studies have attempted to sample human cerebrospinal fluid (CSF) involved in glymphatic clearance for dementia biomarkers during sleep. However, these studies were severely limited by the need for invasive CSF sampling. To address this problem, this proposed study will use a set of newly available, highly sensitive blood based SIMOA assays to study glymphatic function in people treated for severe OSA who undergo CPAP withdrawal. Furthermore, novel methods will be utilized to capture changes in slow wave sleep, blood pressure and brain blood flow together with sleep-wake changes in blood levels of excreted neuro-metabolites to define the pathophysiological mechanisms that inhibit brain cleaning in OSA.

Recruitment information / eligibility

• Status: Enrolling by invitation
• Enrollment: 38
• Est. completion date: December 2024
• Est. primary completion date: September 2024
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 35 Years to 65 Years

Eligibility

Inclusion Criteria:

• Community dwelling adults aged 35-65 years.
• Polysomnography-confirmed severe OSA with apnea hypopnea index (AHI) = 30/hour, with Non-Rapid Eye Movement (NREM) AHI = 15/hour.
• Established CPAP use for treatment of OSA with compliance of > 3 months, with = 5 hours use per night for > 5 nights per week.
• Willing to withdraw from CPAP use for 14 nights.
• Able to give informed verbal and written consent.
• Fluent in spoken, and comprehension of English.

Exclusion Criteria:

• Commercial drivers (e.g.: drivers of heavy vehicles, public passenger vehicles, or vehicles requiring dangerous goods driver license).
• History of severe cardiovascular disease (e.g.: stroke, myocardial infarction, atrial fibrillation).
• Presence of cognitive impairment and/or established diagnosis of dementia.
• Regular use of medications which affect sleep (e.g.: benzodiazepines, opioids, stimulants, sedating antihistamines).
• Regular 24-hour shift workers, presence of jetlag, or history of trans-meridian travel (crossing 2 or more time zones) in the past 2 weeks.
• Advice against withdrawal of CPAP treatment, as determined by the participant's treating physician or study physician.
• Vulnerable to driving impairment without CPAP therapy/upon withdrawal of CPAP therapy, as assessed by: (a) positive response(s) to screening questions in the modified ASTN-Motor Vehicle Accident Questionnaire, reporting driving accidents and/or impairments prior to established CPAP therapy; AND/OR (b) the participant's treating physician.
• Prior history of severe COVID-19 infection involving significant neurological symptoms (e.g.: reduced level of consciousness, delirium, encephalopathy) - warranting hospitalization.
• Current COVID-19 infection and/or experience of ongoing symptoms/sequelae following a recent COVID-19 infection.
• Not up to date with the COVID-19 vaccination schedule - as per the current Australian Technical Advisory Group on Immunization (ATAGI) definition for individuals aged 16

years and over - at the time of writing this Protocol, defined as having:

1. Received 2 primary doses of any Therapeutic Goods Administration (TGA)-approved or TGA-recognized COVID-19 vaccine at least 14 days apart (except for the Janssen COVID-19 vaccine, where only 1 primary dose is required); PLUS

2. A booster dose of a TGA-approved COVID-19 vaccine (Pfizer, Moderna or AstraZeneca) at a recommended interval of 3-6 months after the receipt of 2nd primary dose; OR

3. For severely immunocompromised individuals: received 3 primary doses of any TGA-approved or TGA-recognized COVID-19 vaccine, with dose 3 administered within 6 months of receiving dose 2.

• Other medical conditions deemed by study physicians to warrant exclusion.

Related Conditions & MeSH terms

• Apnea
• Cognitive Dysfunction
• Cognitive Impairment
• Dementia
• Obstructive Sleep Apnea
• Sleep Apnea Syndromes
• Sleep Apnea, Obstructive

Intervention

Other:
• CPAP Withdrawal
Complete withdrawal of continuous positive airway pressure (CPAP) therapy for a 2-week period.

Locations

Country	Name	City	State
Australia	Woolcock Institute of Medical Research	Glebe	New South Wales

Sponsors (2)

Lead Sponsor	Collaborator
Woolcock Institute of Medical Research	National Health and Medical Research Council, Australia

Country where clinical trial is conducted

Australia, 

References & Publications (9)

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. — View Citation

Bucks RS, Olaithe M, Rosenzweig I, Morrell MJ. Reviewing the relationship between OSA and cognition: Where do we go from here? Respirology. 2017 Oct;22(7):1253-1261. doi: 10.1111/resp.13140. Epub 2017 Aug 4. — View Citation

Holth JK, Fritschi SK, Wang C, Pedersen NP, Cirrito JR, Mahan TE, Finn MB, Manis M, Geerling JC, Fuller PM, Lucey BP, Holtzman DM. The sleep-wake cycle regulates brain interstitial fluid tau in mice and CSF tau in humans. Science. 2019 Feb 22;363(6429):880-884. doi: 10.1126/science.aav2546. Epub 2019 Jan 24. — View Citation

Iliff JJ, Wang M, Liao Y, Plogg BA, Peng W, Gundersen GA, Benveniste H, Vates GE, Deane R, Goldman SA, Nagelhus EA, Nedergaard M. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid beta. Sci Transl Med. 2012 Aug 15;4(147):147ra111. doi: 10.1126/scitranslmed.3003748. — View Citation

Ju YS, Zangrilli MA, Finn MB, Fagan AM, Holtzman DM. Obstructive sleep apnea treatment, slow wave activity, and amyloid-beta. Ann Neurol. 2019 Feb;85(2):291-295. doi: 10.1002/ana.25408. Epub 2019 Jan 17. — View Citation

Kang JE, Lim MM, Bateman RJ, Lee JJ, Smyth LP, Cirrito JR, Fujiki N, Nishino S, Holtzman DM. Amyloid-beta dynamics are regulated by orexin and the sleep-wake cycle. Science. 2009 Nov 13;326(5955):1005-7. doi: 10.1126/science.1180962. Epub 2009 Sep 24. — View Citation

Leng Y, McEvoy CT, Allen IE, Yaffe K. Association of Sleep-Disordered Breathing With Cognitive Function and Risk of Cognitive Impairment: A Systematic Review and Meta-analysis. JAMA Neurol. 2017 Oct 1;74(10):1237-1245. doi: 10.1001/jamaneurol.2017.2180. Erratum In: JAMA Neurol. 2018 Jan 1;75(1):133. — View Citation

Xie L, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, O'Donnell J, Christensen DJ, Nicholson C, Iliff JJ, Takano T, Deane R, Nedergaard M. Sleep drives metabolite clearance from the adult brain. Science. 2013 Oct 18;342(6156):373-7. doi: 10.1126/science.1241224. — View Citation

Yaffe K, Laffan AM, Harrison SL, Redline S, Spira AP, Ensrud KE, Ancoli-Israel S, Stone KL. Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA. 2011 Aug 10;306(6):613-9. doi: 10.1001/jama.2011.1115. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Changes in sleep-wake amplitudes (peak-trough) of blood levels of Aß	Difference between the CPAP on and CPAP off conditions in sleep-wake amplitudes (peak-trough) of blood levels of Aß (Aß40/Aß42 ratio), as measured by SIMOA blood neuro-metabolite assays.	Pre- and 2 weeks post-intervention
Secondary	Changes in NREM slow wave parietal cortex activity	Differences between the CPAP on and CPAP off conditions in NREM slow wave parietal cortex activity as measured by high-density EEG (HD-EEG).	Pre- and 2 weeks post-intervention
Secondary	Changes in brain tissue oxygenation during sleep	Differences between the CPAP on and CPAP off conditions in brain tissue oxygenation, as measured by oxygenated and deoxygenated hemoglobin using functional Near Infrared Spectroscopy (fNIRS).	Pre- and 2 weeks post-intervention
Secondary	Changes in brain blood volume during sleep	Differences between the CPAP on and CPAP off conditions in brain blood volume during sleep, estimated by changes in total hemoglobin using functional Near Infrared Spectroscopy (fNIRS).	Pre- and 2 weeks post-intervention
Secondary	Changes in arterial stiffness indices during sleep	Differences between the CPAP on and CPAP off conditions in arterial stiffness during sleep, as measured by the Augmentation Index (%) using pulse wave analysis (PWA) of finger blood pressure waveforms from the Finapres Nova device.	Pre- and 2 weeks post-intervention
Secondary	Changes in central aortic blood pressure during sleep	Differences between the CPAP on and CPAP off conditions in peripheral and central aortic systolic, diastolic and mean blood pressure (mmHg) during sleep using pulse wave analysis (PWA) of finger blood pressure waveforms from the Finapres Nova device.	Pre- and 2 weeks post-intervention
Secondary	Changes in pulse wave velocity (PWV)	Differences between the CPAP on and CPAP off conditions in pulse wave velocity (m/sec), as measured using the SphygmoCor XCEL device.	Pre- and 2 weeks post-intervention
Secondary	Changes in sympathetic and parasympathetic activity during wake and sleep periods	Differences between the CPAP on and CPAP off conditions in sympathetic and parasympathetic activity during wake and sleep periods, as measured by heart rate variability (HRV) analysis of electrocardiogram (ECG) readings.	Pre- and 2 weeks post-intervention
Secondary	Changes in sleep-wake amplitudes (peak-trough) of blood levels of p-tau-180	Difference between the CPAP on and CPAP off conditions in sleep-wake amplitudes (peak-trough) of blood levels of p-tau-180, as measured by SIMOA blood neuro-metabolite assays.	Pre- and 2 weeks post-intervention
Secondary	Changes in sleep-wake amplitudes (peak-trough) of blood levels of p-tau-217	Difference between the CPAP on and CPAP off conditions in sleep-wake amplitudes (peak-trough) of blood levels of p-tau-217, as measured by SIMOA blood neuro-metabolite assays.	Pre- and 2 weeks post-intervention
Secondary	Changes in sleep-wake amplitudes (peak-trough) of blood levels of glial fibrillary acidic protein (GFAP)	Difference between the CPAP on and CPAP off conditions in sleep-wake amplitudes (peak-trough) of blood levels of GFAP, as measured by SIMOA blood neuro-metabolite assays.	Pre- and 2 weeks post-intervention
Secondary	Changes in sleep-wake amplitudes (peak-trough) of blood levels of neurofilament light chain (NfL)	Difference between the CPAP on and CPAP off conditions in sleep-wake amplitudes (peak-trough) of blood levels of NfL, as measured by SIMOA blood neuro-metabolite assays.	Pre- and 2 weeks post-intervention