Background: Patients with sleep apnea have frequent apneas and hypopneas during sleep. Apneas can be either central or obstructive. The apnea-hypopnea index (AHI) is the mean number of apneas and hypopneas per hour of sleep. Aims: 1) To evaluate the effect of a mandibular advancement device on obstructive apneas and sleep; 2) to evaluate the influence of body position on central apnea frequency; 3) to investigate whether obstructive or central apnea is related to mortality in patients with stroke; and 4) to investigate sleep and sleeping positions in women. Methods: Subjects were investigated during whole-night sleep respiratory recordings, either polysomnography including continuous recordings of EEG, EOG, EMG, airflow, respiratory effort, ECG, pulse oximetry and body position, or simplified sleep apnea recordings without EEG, EOG and EMG. Results: The frequency of obstructive apneas, hypopneas and arousals decreased and rapid eye movement (REM) sleep increased in patients with mild, moderate and severe sleep apnea during treatment with a mandibular advancement device. Central apneas were more prevalent in the supine position compared with the non-supine position in patients with Cheyne-Stokes respiration. The mean ± SD central AHI was 41 ± 13 in the supine position and 26 ± 12 in the non-supine position, p<0.001. Stroke patients with obstructive sleep apnea ran an increased risk of death during 10 ± 0.6 years of follow-up with an adjusted hazard ratio of 1.76 (95% CI 1.05-2.95) compared with controls, independent of hypertension, age, body mass index, gender, smoking, diabetes mellitus, atrial fibrillation, Mini-Mental State Examination and Barthel-ADL. Central apnea was not related to early death. Total sleep time, sleep efficiency, rapid eye movement sleep, slow wave and time in the supine position decreased with age in women. Sleep quality in women was reduced with age, body mass index, obstructive sleep apnea, smoking, alcohol and hypertension. Conclusions: Obstructive sleep apneas and arousals are reduced and REM sleep is increased using a mandibular advancement device in patients with mild, moderate and severe sleep apnea. The frequency of central apneas and hypopneas is increased in the supine position in patients with Cheyne-Stokes respiration. Stroke patients with obstructive sleep apnea run an increased risk of early death. Central sleep apnea was not related to early death among the present patients. Normal values for sleep stages and sleeping positions are presented in a population-based sample of women. Age, body mass index, obstructive sleep apnea, smoking, alcohol and hypertension reduce sleep quality in women.

Orientador: Maria Filomena Ceolim / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T23:18:27Z (GMT). No. of bitstreams: 1 Freitas_DeniseCuoghideCarvalhoVerissimo_D.pdf: 2485963 bytes, checksum: 213465114374498d7288558bab3e51d0 (MD5) Previous issue date: 2013 / Resumo: Distúrbios do sono são prevalentes entre idosos e têm sido associados ao desenvolvimento e agravamento de doenças crônicas, com destaque para a hipertensão e o diabetes mellitus (DM). Estas doenças são responsáveis por elevado percentual de morbidade e mortalidade nessa faixa etária. Este estudo teve por objetivos investigar a associação dos sintomas de insônia e do sono diurno igual ou superior a 90 minutos com a ocorrência de hipertensão e DM em idosos, independente da presença de outros fatores de risco; e identificar fatores preditivos desses distúrbios. Constitui um adendo à pesquisa Fragilidade em Idosos Brasileiros (FIBRA), estudo multicêntrico realizado com idosos residentes na comunidade. Utilizou-se o banco de dados da cidade de Campinas - SP, na qual foi avaliada uma amostra aleatória e representativa de 900 idosos. Destes, 689 foram incluídos neste estudo, atendendo a critérios de seleção previamente definidos. Os dados foram submetidos à análise descritiva e inferencial, por meio do teste Qui-quadrado para verificar a associação entre variáveis e análise de regressão logística univariada e múltipla, para investigar a influência dos sintomas de insônia e do sono diurno igual ou superior a 90 minutos na ocorrência de hipertensão e DM, bem como para identificar os fatores preditivos desses sintomas e do sono diurno de longa duração. Verificou-se predomínio das mulheres, dos idosos mais jovens (65 a 69 anos), casados, aposentados, com um a quatro anos de estudo e residentes com a família. Sintomas de insônia foram relatados por 55,0%, sendo mais prevalentes o despertar precoce, a dificuldade de iniciar o sono e o sono não restaurador. Sono diurno com duração igual ou superior a 90 minutos foi referido por 9,9% dos idosos. Os fatores associados à hipertensão, segundo o modelo de regressão logística múltipla, foram o IMC indicativo de pré-obesidade ou obesidade, os sintomas de insônia e o sedentarismo; para o DM, mostraram-se associados aos não brancos e ao alto risco da relação cintura/quadril. Quanto aos sintomas de insônia, os fatores associados foram à avaliação subjetiva da saúde regular, ruim ou muito ruim, a situação de não estar aposentado e a depressão. A presença de enfisema/bronquite foi o único fator associado ao sono diurno com 90 minutos ou mais de duração. Estes achados alertam os profissionais de saúde para que investiguem sintomas de insônia, mesmo na ausência de queixas dos idosos. As informações coletadas poderão contribuir na prevenção de possíveis agravos à saúde, bem como para subsidiar políticas públicas de prevenção e tratamento. Este projeto está inserido na Linha de Pesquisa "Processo de Cuidar em Saúde e Enfermagem" / Abstract: Sleep disorders are prevalent among the elderly and have been recently associated with the development and worsening of chronic diseases, especially hypertension and diabetes mellitus (DM). These diseases are responsible for high rates of morbidity and mortality in this age group. This study aimed to investigate the association between insomnia symptoms and daytime sleep over 90 minutes with the occurrence of hypertension and DM in the elderly regardless of the presence of other risk factors, and to identify predictive factors of these disorders. It is an addendum to the research Frailty in Brazilian Elderly (FIBRA), multicenter study with elderly community residents. We used the database of Campinas - SP, in which it was, assessed a representative random sample of 900 elderly. Of these, 689 were included in this study, given the selection criteria previously defined. Data were analyzed by descriptive and inferential statistics, using Chi-square test to determine the association between variables, and logistic regression analysis, univariate and multivariate, to investigate the influence of symptoms of insomnia and daytime sleep over 90 minutes in the occurrence of hypertension and DM, as well as to identify factors predictive of insomnia symptoms and long lasting daytime sleep. Results showed a predominance of women, young-old (65 to 69 years), married, retired, with one to four years of formal education, living with relatives. Insomnia symptoms were reported by 55.0%. Mostly frequent insomnia symptoms were early morning awakening, difficulty initiating sleep and non-restorative sleep. Daytime sleep 90 minutes or longer was reported by 9.9% of the elderly. Factors associated with hypertension, according to multiple logistic regression model, were BMI indicative of pre-obesity or obesity, insomnia symptoms and physical inactivity; for DM, associated factors were nonwhite and high risk waist-to-hip relationship. As to insomnia symptoms, risk factors were subjective evaluation of health as fair, poor or very poor, the situation of not being retired and depression. Presence of emphysema/bronchitis was the only factor associated with daytime sleep of 90 minutes or longer. These findings alert health professionals to investigate symptoms of insomnia, even in the absence of complaints from the elderly. They may also help in preventing possible harm to health as well as to support public policies for prevention and treatment. This project is included in the Research Line "Process of Caring in Nursing and Health" / Doutorado / Enfermagem e Trabalho / Doutora em Ciências da Saúde

Tato diplomová práce se zabývá metodami pro analýzu a klasifikaci spánku. Popisuje jakjednotlivé spánkové fáze a vzorce biosignálů v průběhu spánku, tak metody pro klasifi-kaci. Příznaky jsou extrahovány na dodaných biosignálech ECG, EDA a RIP. Na základětěchto příznaků jsou klasifikovány jednotlivé spánkové fáze s využitím klasifikátoru ná-hodný les. Parametry klasifikátoru jsou optimalizovány a následně jsou vyhodnocenydosažené výsledky. Pomocí metod pro redukci dimenzionality je soubor příznaků analy-zován a výsledky jsou porovnány s výsledky ze standardní klasifikace. Řešení pro vizuali-zaci jak samotných nezpracovaných signálů, tak extrahovaných příznaků je navrhnuto aimplementováno. Dosažené výsledky jsou porovnány s publikovanými metodami.

The thesis is focused on automatic classification of polysomnographic signals based on various parameters in time and frequency domain. The parameters are acquired from 30 seconds long segments of EEG, EMG and EOG signals recorded during different sleep stages. The parameters used for automatic classification of sleep stages are selected according to statistical analysis. Classification is performed using the SVM method and evaluation of the success of the classification is done using sensitivity, specificity and percentage success. Classification method was implemented using Matlab.

我們提出的智慧型睡眠監測系統，是基於影像分析技術進行睡眠品質觀測，並利用所得到的數據來推斷最佳的喚醒時間。此系統命名為iWakeUp，利用非接觸式的方法來收集影像資料並進行後續處理，此裝置將被安裝在一般的臥室來幫助睡眠者，以期成為增進智慧家庭生活品質的一環。在此論文中，我們將會描述iWakeUp的各個模組包括測定動作量、推斷睡眠階段乃至於如何建立喚醒機制。更特別的是，我們考慮了喚醒時間與喚醒機制的關係，於較早的時間喚醒必須具有更高的信心度，否則將付出較大的代價，反之亦然。另外為了處理晨間臥室中的光影變化，不同的背景模型也已被整合測試，以期讓系統可以提升長時間觀測的準確度。最後，我們也進行了使用iWakeUp的臨床實驗，結果指出使用iWakeUp喚醒的睡眠者具有較低的嗜睡感與更好的活力。 / We present a video-based monitoring system to determine the sleep status and optimal wakeup time in this thesis. We envision a smart living space in which a data collection and processing module named iWakeUp is installed in the bedroom to record and monitor sleep in a non-invasive manner. We describe the overall structure of the iWakeUp system, including the procedure to measure amount of motion, the method for inferring wake/sleep status from the acquired video and the logics for deciding the optimal wakeup time. In particular, a time-dependent decision rule has been incorporated to account for unequal penalties when classification error occurs. Furthermore, various background modeling techniques have been examined to address lighting changes at dawn in the bedroom for long-term monitoring. Validation experiments are carried out to compare the alertness level upon awakening with/without reported a lower level of sleepiness and higher level of vigorousness in comparison to the control group.

The thesis is focused on analysis of polysomnographic signals based on extraction of chosen parameters in time, frequency and time-frequency domain. The parameters are acquired from 30 seconds long segments of EEG, EMG and EOG signals recorded during different sleep stages. The parameters used for automatic classification of sleep stages are selected according to statistical analysis. The classification is realized by artificial neural networks, k-NN classifier and linear discriminant analysis. The program with a graphical user interface was created using Matlab.

Le sommeil joue un rôle important dans la consolidation de la mémoire. Les expériences nouvellement acquises à l’éveil sont réactivées spontanément durant le sommeil, un processus qui aiderait à consolider et intégrer la mémoire à plus long terme. Il a été suggéré que ces réactivations de mémoire se reflétaient, du moins partiellement, dans le contenu des rêves et que les rêves pouvaient jouer un rôle actif dans la consolidation de la mémoire. L'objectif général de cette thèse de doctorat est ainsi d'évaluer si et comment le rêve est impliqué dans le traitement de la mémoire épisodique et procédurale en utilisant de nouvelles technologies et approches expérimentales pour étudier ces relations. La première étude de cette thèse visait à influencer les réactivations de mémoire durant le sommeil afin de clarifier leurs liens avec les rêves et la mémoire procédurale. Nous avons stimulé ces réactivations de mémoire en réexposant des participants, durant leur sommeil, à un stimulus sonore préalablement associé à un apprentissage moteur, une approche nommée « targeted memory reactivation » (TMR). Nous montrons que la TMR, lorsqu’appliquée en stade de sommeil paradoxal, permet d’améliorer l’apprentissage d’une tâche motrice complexe, soit apprendre à « voler » en réalité virtuelle. De plus, le fait de rêver à des éléments kinesthésiques de la tâche motrice en sommeil paradoxal, mais pas en sommeil lent léger, est associé à une meilleure amélioration à cette tâche (article I). Ces résultats appuient les modèles suggérant que le sommeil paradoxal joue un rôle important dans la consolidation de la mémoire procédurale complexe et suggèrent en outre que la simulation de sensations sensorimotrices dans les rêves pourrait contribuer à ce rôle. Bien que la TMR n’ait pas eu d’impact direct sur les rêves, nous montrons qu’elle peut influencer le décours temporel des incorporations de mémoire dans les rêves sur plusieurs jours. La TMR a amplifié les incorporations tardives de la tâche, soit 1-2 jours plus tard lorsqu’appliquée en sommeil paradoxal, et 5-6 jours plus tard lorsqu’appliquée en sommeil lent profond (article II). Nous suggérons que ces effets à plus long terme pourraient être dus à un mécanisme de marquage (tagging) des traces de mémoire, initiant ou amplifiant leur traitement subséquent au cours de plusieurs nuits de sommeil. De plus, nous montrons que notre expérience immersive en réalité virtuelle a augmenté l’incorporation de sensations de vol dans les rêves, particulièrement la nuit suivant l’exposition à celle-ci (article III). Nous identifions certains facteurs individuels qui sont associés à une plus grande incorporation de la tâche dans les rêves, tels que le fait d’avoir déjà eu des rêves de vols ou des rêves lucides. Un examen plus approfondi des rêves pendant 10 jours suivants l'expérience de réalité virtuelle montre que les sensations de vol sont progressivement décontextualisées du contexte de vol original au fil du temps. Les rêves de vol après l’expérience en réalité virtuelle avaient également des niveaux de contrôle et d'intensité émotionnelle plus élevés que ceux ayant eu lieu avant l’expérience. L'induction de rêves de vol nous a permis de faire une analyse qualitative approfondie sur ceux-ci, menant à une nouvelle proposition de la manière dont les sensations de vol, ou les sensations de mouvement de manière plus générale, peuvent survenir dans les rêves. Ces résultats pourraient à leur tour faciliter le développement de technologies pour mieux influencer et étudier les rêves. Une deuxième étude visait à évaluer quand et comment une source de mémoire épisodique commune à tous les participant – visiter le laboratoire de sommeil – est incorporé dans les rêves. Les résultats montrent que près du tiers des rêves incorporent des éléments du laboratoire, et ce, particulièrement dans les rêves en sommeil paradoxal lors d’une sieste matinale (article IV). Une étude qualitative de ces rêves met de l’avant les manières typiques par lesquelles des éléments du laboratoire réapparaissent dans les narratifs de rêve. Nous proposons l’existence de différentes « pressions intégratives » qui structurent les fragments de mémoire au sein de scénarios de rêves. Souvent, ces scénarios impliquent une certaine pression de performance, sont de nature sociale, projettent le rêveur dans le temps et dans l’espace, ou incorporent des sensations réelles du corps et de l’environnement de sommeil. Étudier le phénomène de « rêver au laboratoire » aide ainsi à clarifier comment les rêves sont façonnés autour de fragments de mémoire et souligne à la fois les avantages et les limites méthodologiques de l’étude des rêves et de la mémoire en laboratoire. Finalement, une troisième étude visait à suivre le décours temporel des sources de mémoire autobiographique des rêves au cours d’une nuit de sommeil entière en utilisant un protocole de réveils en série. Nos résultats montrent que les rêves peuvent combiner plusieurs sources de mémoire, en particulier lorsqu'ils se produisent en stade N1 ou en sommeil paradoxal, ce qui pourrait refléter une plus grande richesse ou capacité intégrative des rêves ayant lieu en ces stades (article V). Nous reproduisons le résultat voulant que les souvenirs récents sont préférentiellement réactivés tôt dans la nuit, tandis que les souvenirs plus lointains sont relativement plus représentés dans les rêves de fin de nuit – nous précisons que cet effet est indépendant des stades de sommeil. La co-activation de plusieurs sources de mémoire dans un même récit de rêve appuie la suggestion que l’une des fonctions du sommeil est d'intégrer les nouvelles connaissances à nos réseaux de mémoire préexistants. Nos résultats suggèrent que cette fonction pourrait être un processus cumulatif au cours d'une nuit de sommeil. Nous montrons entre autres qu'une seule source de mémoire peut être réactivée à plusieurs reprises dans plusieurs rêves, et en différents stades de sommeil, ce qui pourrait permettre un traitement continu ou séquentiel de souvenirs épisodiques avec d'autres souvenirs tout au long de la nuit. Dans l’ensemble, nos études quantitatives et qualitatives des incorporations de mémoire dans les rêves permettent d’éclairer les mécanismes fondamentaux de la formation des rêves ainsi que leurs associations avec le traitement et la consolidation des mémoires épisodique et procédurale. Nos résultats suggèrent qu’un rôle potentiel du rêve dans la mémoire irait au-delà de sa simple réactivation, soutenant des processus de transformation et d’intégration de la mémoire. La création de scénarios multisensoriels et immersifs basés sur des fragments mémoire est possiblement centrale à ces processus et permettrait d’optimiser l’utilisation de la mémoire pour le futur. / Sleep plays an important role in memory consolidation. New experiences acquired while awake are reactivated spontaneously during sleep, a process that is thought to facilitate their consolidation and integration into longer-term memory. It has been suggested that these memory reactivations are, at least partially, reflected in dream content and that dreams play an active role in memory consolidation. The general objective of this doctoral thesis is to assess these claims; I examine whether and how dreams are involved in episodic and procedural memory processes by using new technologies and experimental approaches to study relationships between memory and dreaming. Our first study aimed to influence memory reactivations during sleep in order to clarify their relationships with dreams and procedural learning. We experimentally stimulated memory reactivations by re-exposing participants during their sleep to an auditory stimulus previously associated with motor learning, a process called targeted memory reactivation (TMR). We show that TMR, when applied during rapid eye movement (REM) sleep, improves performance of a complex motor task, i.e., learning how to "fly" in a virtual reality (VR) setting. Moreover, dreaming about kinesthetic elements of the motor task in REM sleep, but not in stage 2 sleep, is associated with better improvement on this task (article I). These results support previous models suggesting that REM sleep plays an important role in the consolidation of complex procedural memory and further suggest that the simulation of sensorimotor sensations in dreams contribute to this role. Although TMR did not directly impact dreams, we show that it can influence the time course of memory incorporations in dreams over multiple days. It amplified delayed incorporations of the task 1-2 days later when applied in REM sleep, and 5-6 days later when applied in slow-wave sleep (article II). We suggest that these longer-term effects could be due to a “tagging” mechanism of memory traces, which primes or amplifies their subsequent processing over several nights of sleep. Furthermore, we show that our immersive VR task increased the incorporation of flying sensations in dreams, especially the night after exposure to it (article III). We identify individual factors that are associated with the incorporation of the flying task in dreams, such as previous experience with both flying and lucid dreams. A closer look at dreams over 10 days following the VR experience shows that flying sensations become progressively decontextualized from the original flying context over time. Flying dreams after VR exposure also had higher levels of control and emotional intensity compared to baseline flying dreams. The successful induction of flying dreams allowed us to do an in-depth qualitative analysis of them, based on which we propose a new mechanistic explanation of how flying sensations or movements may arise in dreams. These results could facilitate the development of technologies to better influence and study dreaming. Our second study aimed to assess when and how an episodic memory source shared by all participants – visiting the sleep laboratory – is incorporated into dreams. The results show that almost a third of dreams incorporate elements of the laboratory, particularly REM dreams from a morning nap (article IV). A qualitative study of these dreams highlights the typical ways in which elements of the laboratory reappear in dream narratives. We suggest the existence of different “integrative pressures” that structure memory fragments into these dream scenarios. These are often performative or social in nature, project the dreamer in time and space, or incorporate real sensations from the sleeping body or the sleep environment. Studying the phenomenon of dreaming about the laboratory helps clarify how dreams are shaped from memory fragments, and highlights the advantages and methodological limits of laboratory dream and memory studies. Finally, our third study evaluated the time course of autobiographical dream memory sources during an entire night of sleep using a serial awakenings protocol. Our results show that dreams can combine multiple memory sources at once, especially when they occur at sleep onset or in REM sleep, which may reflect a greater dream richness or a more widespread associative memory activation in those stages (article V). We replicate the finding that recent memories are preferentially reactivated early in the night, while more distant memories are relatively more represented in late night dreams – we here clarify that this effect is independent of sleep stages. The coactivation of multiple memory sources in a dream narrative aligns with the suggestion that a function of sleep is to integrate new knowledge with existing knowledge. Our results further suggest that the latter may be a cumulative function of a night of sleep. We show that a single memory source can be repeatedly reactivated in multiple dreams in different sleep stages, which could allow a continuous or sequential processing of episodic memories with other memories across the night. Overall, our quantitative and qualitative studies of memory incorporations in dreams shed light on fundamental mechanisms of dream formation and on their association with episodic and procedural memory processing and consolidation. Our results suggest that a potential role of dreams in memory goes beyond simple reactivation, supporting long-term processes of memory transformation and integration. The creation of immersive and multisensory dream scenarios built upon memory fragments may be key to these processes and to optimizing the use of these memories for the future.