The case for improving the detection and treatment of obstructive sleep apnea following stroke
Obstructive sleep apnea (OSA) is prevalent and harmful after stroke.
Investigation of sleep disorders, particularly OSA, should be strongly considered for patients who have had a stroke, with the goal of improving nonvascular outcomes.
Obstructive sleep apnea should be treated like a vascular risk factor.
Future trials will assess whether treatment for OSA initiated early after stroke reduces stroke recurrence.
Stroke is a leading cause of death and disability for people in Canada. Beyond the initial brain injury, the sequelae of stroke may also include several comorbidities, with sleep disorders being among the most important. Obstructive sleep apnea (OSA) and sleep–wake disturbances are highly prevalent among patients who have had a stroke; they may be both a risk factor for and a consequence of stroke, and can substantially affect stroke recovery and functional outcomes.1 Moreover, post-stroke fatigue is a top research priority for patients who have had a stroke.2
In related research, Jeffers and colleagues3 used cross-sectional data from the Canadian Community Health Survey to study relative rates of 4 self-reported sleep disturbances, namely having trouble staying awake, either short (< 5 h) or long (> 9 h) nightly sleep duration, having trouble going to or staying asleep, and having unrefreshing sleep. Almost two-thirds of respondents who reported a history of stroke also reported sleep difficulties; those with a history of stroke also reported each form of sleep disturbance significantly more frequently than those without a history a stroke.
Although the authors of the related research did not specifically examine OSA, many of the sleep concerns among those who reported a history of stroke were likely driven by OSA, the most common post-stroke sleep disorder, which has been reported to occur in as many as 72% of patients who have had a stroke or transient ischemic attack (TIA), depending on OSA severity.4 Patients with pre-existing OSA have poorer functional outcomes and spend more time in rehabilitation after a stroke.5 Randomized controlled trials have shown that treatment of post-stroke OSA using continuous positive airway pressure (CPAP) improves neurologic recovery and quality of life, and reduces daytime sleepiness and depressive symptoms.6,7
Given that OSA is a well-established risk factor for stroke, with a greater adjusted relative risk for stroke similar to or higher than traditional modifiable vascular risk factors that are commonly managed after stroke,8 it would make sense that OSA be routinely screened for and treated after stroke. However, a 2019 study suggested otherwise.9
Lack of screening for OSA after stroke may be explained by several barriers. Obstructive sleep apnea often presents atypically after stroke, and many patients with OSA who have had a stroke do not have the typical clinical features of OSA, such as obesity and daytime sleepiness.10 Many clinicians may be unaware of the importance of managing OSA and any associated symptoms after stroke. Moreover, testing for sleep disorders requires a multidisciplinary approach, and stroke rehabilitation centres may not have the necessary expertise to conduct sleep testing. Furthermore, the current gold standard for diagnosing OSA, in-laboratory sleep testing or polysomnography, is inconvenient for patients who are vulnerable and those with disabilities, and access to such testing in some Canadian centres may be limited. In a randomized controlled trial that assigned 250 consecutively recruited patients with a history of stroke or TIA to either ambulatory or in-laboratory sleep testing, rates of OSA diagnosis and treatment, as well as functional outcomes and daytime sleepiness, were significantly improved in the ambulatory testing arm.11 These results suggest that removing the barriers associated with in-laboratory sleep testing (through the use of ambulatory testing for OSA) may enhance outcomes among patients who have had a stroke or TIA.
Finally, screening for and management of OSA after stroke is underemphasized in stroke guidelines. For example, the 2014 and 2018 guidelines from the American Heart Association and the American Stroke Association for the secondary prevention of stroke stated that evaluation for OSA “may be considered” for patients with stroke or TIA.12 The most recent version of the Canadian Stroke Best Practice Recommendations removed recommendations on management of sleep apnea,13 although earlier versions did comment on OSA.
Fundamental to the question of whether clinicians should screen for and manage OSA after TIA or stroke is whether treatment of OSA after stroke or TIA reduces incident vascular events or mortality. Although studies assessing the impact of CPAP on nonvascular outcomes among patients with post-stroke OSA have shown positive outcomes, trials evaluating whether CPAP can reduce the risk of incident stroke or death have been largely negative.6 The largest of these trials, the Sleep Apnea Cardiovascular Endpoints (SAVE) trial,7 randomized 2717 patients with coronary or cerebrovascular disease (including 1432 with ischemic stroke or intracerebral hemorrhage) to receive CPAP or usual care. Although the overall findings showed no significant reduction in risk of vascular events or death, a preplanned post hoc subgroup analysis showed that patients who had good adherence to CPAP had a significantly lower risk of cerebrovascular events than those in the usual care group. This was consistent with the findings of earlier, smaller trials that also showed that significant reductions in incident vascular events occurred in subgroups with good CPAP adherence. 14,15 Since randomization was not respected in these subgroup analyses, the findings should be interpreted with caution.
It is important to note that the evidence for various interventions in stroke care has varied over time. Evidence related to OSA is rapidly evolving, and future trials that look at outcomes related to OSA after stroke will need to reconsider how OSA is defined and consider selecting patients on the basis of distinct clinical phenotypes. 16,17 For patients who cannot tolerate CPAP, many new treatment alternatives — including use of pharmacological agents, hypoglossal nerve stimulation, oropharyngeal exercises and dental appliances — have been shown to be effective outside of the stroke population; these need to be evaluated for patients who have had a stroke or TIA.18 Reflecting what has been seen in other studies evaluating secondary stroke prevention strategies (e.g., antiplatelet trials), interventions for OSA will need to be administered in the hours and days after stroke and not in a delayed fashion, as was done in the SAVE trial. Furthermore, in future trials, sample sizes and follow-up periods need to be carefully calculated to assure adequate power and outcome assessment.6
Investigation of sleep disorders, particularly OSA, should be strongly considered for patients who have had a stroke, with the goal of improving nonvascular outcomes, such as daytime sleepiness, mood and functional outcomes. A good argument can be made for treating OSA like any other vascular risk factor.8 Future trials, such as the ongoing Sleep for Stroke Management and Recovery Trial (Sleep SMART Trial; NCT03812653), will assess whether CPAP treatment for OSA that is started early after stroke reduces stroke recurrence.
Competing interests: Mark Boulos reports funding from the Canadian Institutes of Health Research, Canadian Partnership for Stroke Recovery, Alternative Funding Plan from the Academic Health Sciences Centres of Ontario, Ontario Genomics and McLaughlin Centre for Molecular Medicine. He also reports consulting fees and honoraria from Jazz Pharmaceuticals, Paladin Labs, Eisai and the OntarioMD Peer Leader Program; travel support from McGill University; and receipt of sleep equipment or research support from Braebon Medical Corporation, The Mahaffy Family Research Fund and Green Mountain.
This article was solicited and has not been peer reviewed.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
Funding runs out for COVID Assessment and Testing Centres – The Bay Observer – Providing a Fresh Perspective for Hamilton and Burlington
The COVID-19 Testing and Assessment Centre and the Flu, COVID and Cold Clinic at the West 5th Campus will be closed at the end of this month. The move is in response to a sustained drop in the prevalence of COVID-19 and a decline in appointment bookings for testing, attributed to uptake in vaccinations, higher levels of immunity, and declining circulation of the virus in the community. It also reflects the fact that provincial funding for these sites ends on March 31st. The Hamilton site was operated in conjunction with HHSC.
Says Dr. Greg Rutledge, Deputy Chief of Staff, St. Joseph’s Healthcare Hamilton. “It’s been a long time getting to this point where we see a significant drop in COVID-19 transmission.”
The hospital says Ready access to COVID-19 testing in the community through most pharmacies will meet the needs of the public and health care workers.
The move comes as the Globe and Mail published a story noting that these sites served the additional purpose of diverting many patients from Emergency Rooms. In the case of similar centres operating in the Toronto area, and estimated 14,500 potential ER visits were diverted.
According to the Globe and Mail, “Ontario Health described these clinics as a model for providing the right care to patients in the right place at the right time. They demonstrated an ability to optimize resources and reduce the burden on emergency departments. Most clinics have been set up in what are considered high-priority areas, located near public transit. All are accessible by wheelchair and able to provide translation in multiple different languages.” The article quotes Dr Sajjad Dr. Tavassoly, who works at a Brampton centre slated for closure as saying said what frustrates him most is the unmet needs of the community continue to grow, regardless of the government’s March 31 funding expiry.
More than 390,000 tests have been done at the West 5th Testing and Assessment Centre through the past three years.
The last day of operation for both the Testing and Assessment Centre and the Flu, COVID and Cold Clinic will be Friday, March 31, 2023.
Those With Rare Diseases Need to Wait, as Usual
Science has developed the ability to research, develop and create functional cures for many of our so-called “incurable diseases”, but having the ability to do something and actually doing it are two different things. Medicine has always suffered from a problem with “knowing-doing”. It is the difference between what a doctor actually does for a patient and what can be done with all that we know. Developmental breakthroughs in medicine are allowing doctors to do things they never could imagine before. Sometimes these break-thoughts don’t fit into businesses/governmental financial or regulatory systems, meaning that it can take a long time for patients to actually benefit, a time many patients may not have.
The National Institutes of Health in America invest more than $40 Billion in biomedical research each year, and the private sector twice as much. The discoveries are valued by all, but why is it so hard to use these discoveries?
Science’s ability to engineer medicines has far outpaced how these medicines are actually built, tested, and put into human beings. Artificial Intelligence has assisted the community by mapping the human genome in efforts to cure various diseases. The US Government defines rare diseases as those that affect fewer than 200,000 people in America. Some affect only a handful of people. There are over 7000 different rare diseases, with more than 30 million people in America diagnosed with one of them. That is 10% of the US population. So improving how society can find and care for these patients could have a great impact. Problem is that the health system is not flagging enough people with these diseases, while many individuals don’t even know what disease they may have, or that they indeed have a disease. A.I. steps up front to assist in the recognition, tracking, analyzing, and identifying of these patients through computer-programmed systems. Put one’s symptoms into the machine, and often voila, a point from which a doctor can begin his medical investigation and treatment. A diagnostic odyssey in each individual case.
Artificial Intelligence has a prominent place within our health system, including helping design new treatments, helping predict which treatment is better for which patient, and screening for rare diseases with suggested diagnoses to boot. Why are many with rare diseases often left out in the cold, to search on their own for a cure? Money! Simple.
Who makes medicines, and invests millions in treatments and research for diseases? Pharmaceutical Firms.
What are they but profit centers for investment bankers, massive corporations, and a financial structure centered upon the shareholder, and not the average joe? Solutions can be found, but the willingness to spend way beyond what a firm can make in profits needs to be there. Sure our DNA is constantly changing, and evolving biologically. Making a drug that cures cancer, may cure some, but certainly not all forms since each person is unique, their biology specific to that person. Many doctors realize that their methods are much like witch Doctors, forever experimenting with the specific individual’s condition.
Our Health system is tied to our financial system. That is the root of it. So long as the doctors, hospitals, and researchers are tied to profit (our financial system) the necessary technology, research, and investment will not be found for those with rare diseases. I have a disease that has no cure. My immune system is attacking the tissue in my mouth. It is sorely painful, personally transformative, and damn if you could find a doctor who is a real expert in the field. Since it is rare, the institutions of the industry will not find proper medicine for its management, let alone its cure. I live with it, and the disease manages the way I eat, what I eat, how I clean my teeth, how I sleep, and interact with my partner too. This disease can transfer to another. Great eh!
For those of you who have or know of someone who has a rare disease, all I can say is to be patient. The present-day financial and healthcare systems need to change drastically, with governmental intervention in all aspects of research, planning, and manufacturing of medicines. Out of the hands who care for themselves, and hopefully into the hands of those who care about you and those you love.
The Healthcare Systems Failing Continually
North Americans are aging, while the number of births within the tri-nation continent is continually falling. Birth Rates in the Caribbean have been stagnating since 2023 now showing a 7.5% decline. If national governments could dream this would be a nightmare. National union’s pension plans are at risk, as the number of workers declines but the number of pensioners continues to grow. No corporation can run properly in this fashion, much like the California Banks which recently were shut down because they spent more money than they made.
By 2046, 4.6 million Ontarians will be aged 85 and older. The province has fewer than 500 hospice beds and 4,000 hospital palliative care beds available. Ontario’s Healthcare Ministry and the many hospitals its controls are not prepared for the massive growth rate and demands of the aged. Like a car used a great deal, it breaks down. So to our aged population who do experience illness and disease. Ontario does not have enough nonprofit hospices, old age homes, long term care facilities now, and with the upswing of conservatism within Canada, the USA, and the Caribbean there will be a movement towards restraint at a time when necessary investments in these aged services and institutions present themselves. This seems to be typical for our present-day governmental administrations who lack an interest in long-term planning, with the needed revenue investments to be made for near future population demands. Migrants’ can be brought into our lands, but their training in the many fields required will certainly take a lot of time. The time our population does not have.
What is needed? With the present-day migration of nurses, medical professionals, and doctors moving from the Caribbean to the USA and Britain, the demand for trained professionals specializing in aged medicine, bereavement and grief training, hospice palliative care, Navcare to help clients find the services they need has increased at an urgent pace. Volunteers are being trained and relied upon to carry out the needed services that missing professionals should be doing. The management within many facilities has allowed friends and family to fill these positions. While community involvement is commendable, what are our taxes paying for here? Medical, hospital, and hospice centers are under the management and direction of the healthcare ministry, and these ministries are simply not doing the job they were assigned. Lack of funds, certainly lack of personnel, and lack of future financial gain have drained our healthcare ministries of their potential. Lives are at stake, and our politicians seem to be willing to fight the nurses, and healthcare professional union rather than carry out the needed governmental process. Stingy governments invest in the police, military, and economic growth of the state while their fellow citizens suffer and sometimes perish.
The healthcare systems respond by training people and sending them into areas within the system that will reduce emergency room visits, hoping to reduce hospital stays and make it possible for aging clients to stay in their homes. Such protocols are being carried out in Oxford(UK), British Columbia, and Scandinavia. Hospice technicians have been successful within their practicing regions, utilizing various professions in a team atmosphere. Many Traditional Medical Professionals within the hospital setting view these hospice professionals with prejudice and suspicion, creating further tensions within the healthcare system.
The Pandemic has shown us that our healthcare system was not prepared in any way to respond effectively, and the systems managers concentrated on revenue expenditures instead of being prepared for any eventuality. No plans on how to respond, no excess staff to rely upon. This health event has happened before, yet those we rely upon claimed innocence in their often failed reactions.
The aged within our area will also suffer a similar fate when our healthcare system and its managers fail to prepare, plan for, train, and hire needed staff. It is all about the money after all. Problem is that it is our taxes paying for these services, the managers and politicians to prepare and function for us, with us effectively. What do you do when you do not get the customer service you expect and are paying for? Is it time that our multi-system healthcare systems to be transformed?
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