As family medicine continues to evolve, members of the interprofessional team can find it challenging to stay up-to-date on the latest research. Increasing demands on time and resources can make it even harder to be aware of key advances that could affect daily practice. This program highlights 3 recent news articles in sleep medicine that may have broad implications for patient care.

DISORDERED SLEEP TIED TO A MARKED INCREASE IN STROKE RISK

The first article highlights the important relationship between sleep and stroke risk.^[1] Approximately 795,000 people in the United States experience a stroke each year.^[2] Stroke also remains a leading cause of death: it has been estimated that someone in the United States dies of stroke every 3.5 minutes.^[2] Understanding the complex relationship between sleep health and stroke could help identify patients at risk for stroke before it occurs.

Disordered sleep is associated with a significantly increased risk for stroke, new research shows. Results of a large international study show stroke risk was more than 3 times higher in those who slept too little, more than twice as high in those who sleep too much, and 2 to 3 times higher in those with symptoms of severe obstructive sleep apnea (OSA).

The study also showed the greater the number of sleep disorder symptoms, the greater was the stroke risk. The 11% of study participants with 5 or more symptoms of disordered sleep had a fivefold increased risk for stroke. Although the study data do not show a causal link between disordered sleep and stroke, the association between the 2 was strong.

"Given the association, sleep disturbance may represent a marker of somebody at increased risk of stroke and further interventional studies are required to see if management can reduce this risk," lead investigator Christine McCarthy, MD, PhD, a geriatric and stroke medicine physician and researcher with the University of Galway, Galway, Ireland, told Medscape Medical News. "In the interim, however, management of sleep disturbance may have a positive impact on a patient's quality of life."

The findings were published online April 6 in the journal Neurology.^[1]

More Symptoms, More Risk

Previous research shows severe OSA doubles the risk of stroke and increases the chance of recurrent stroke.^[3] A 2019 study showed people with insomnia had a small increased risk of stroke.^[4]

"Both snoring and extremes of sleep duration have been previously associated with an increased risk of stroke in observational research, but less is known about other symptoms of sleep impairment, with less consistent findings," McCarthy said.

Prior studies also have generally come from a single geographic region, which McCarthy noted could limit their generalizability.

For this effort, investigators used data from 4496 participants in INTERSTROKE, an international case-control study of risk factors for a first acute stroke. About half of the participants had a history of stroke.

Using information collected from a survey of sleep habits, researchers found an elevated stroke risk in those who received less than 5 hours of sleep per night (odds ratio [OR], 3.15; 95% CI, 2.09, 4.76) or more than 9 hours of sleep per night (OR, 2.67; 95% CI, 1.89, 3.78) compared with those who slept 7 hours a night.

Participants who took unplanned naps or naps lasting an hour or more (OR, 2.46; 95% CI, 1.69, 3.57) and participants who reported poor quality sleep (OR, 1.52; 95% CI, 1.32, 1.75) also were at increased risk for stroke.

Symptoms of OSA were also strongly associated with increased stroke risk, including snoring (OR, 1.91; 95% CI, 1.62, 2.24), snorting (OR, 2.64; 95% CI, 2.17, 3.20), and breathing cessation (OR, 2.87; 95% CI, 2.28, 2.60).

Stroke risk increased as the number of sleep disturbance symptoms rose, with the greatest risk in the 11% of participants who had 5 or more symptoms (OR, 5.38; 95% CI, 4.03, 7.18).

"This study finds an association between a broad range of sleep impairment symptoms and stroke, and a graded association with increasing symptoms, in an international setting," McCarthy said.

Researchers aren't sure what's driving the higher stroke risk among people with sleep disturbances. Although the study did control for potential confounders, it wasn't designed to get at what's driving the association.

"Sleep disturbance may also have a bi-directional relationship with many stroke risk factors; for example, sleep disturbance may be a symptom of disease and exacerbate disease," McCarthy said. "Future interventional studies are required to determine the true direction of the relationship."

A Marker of Stroke Risk

Commenting on the findings for Medscape Medical News, Daniel Lackland, DrPH, professor of neurology at the Medical University of South Carolina in Charleston, said the findings provide additional evidence of the link between sleep and stroke risk.

"The results confirm sleep disorders as a potential marker and part of the risk profile," he said.

Collecting information about sleep using a validated assessment tool is an important piece of clinical care, Lackland said, especially among patients with other stroke risk factors.

One limitation of the study was that data on sleep were collected only at one point and participants were not followed over time to see if changes in sleep affected stroke risk. "This is an important point and should be a focus for future studies, as it is critical in the design of interventions," Lackland said.

Implications for the Interprofessional Healthcare Team

• People with sleep disturbances have an increased risk of stroke
• Asking patients about their sleep habits, including snoring, napping, sleep quality, and duration of sleep, could help identify patients at risk for stroke
• Use of a validated assessment tool for sleep health should be considered as part of routine care, particularly for patients with additional stroke risk factors

The INTERSTROKE study is funded by the Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), Merck Sharp & Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke. McCarthy and Lackland report no relevant financial relationships.

MANY LONG COVID PATIENTS HAVE SLEEP PROBLEMS

The second article highlights the prevalence of sleep disturbances in patients with post-COVID conditions, or long COVID.^[5] Long COVID can occur in anyone with prior exposure to the SARS-CoV-2 virus, including children and adolescents.^[6] Patients with long COVID often have symptoms that are difficult to explain, measure, and manage.^[6] Given the impact of sleep disturbances on health and quality of life, it remains an important -- but possibly overlooked -- symptom of long COVID.

Study Synopsis

Four in 10 people with long COVID had moderate to severe sleep problems, and Black people with the condition were much more likely to have serious sleep issues, a new study found.

The study was published this week in the Journal of General Internal Medicine.^[5]

The study included 962 adults at the Cleveland Clinic who were treated for long COVID -- what the researchers defined as having lingering and debilitating symptoms from the virus lasting more than 4 weeks -- at the Cleveland Clinic between February 2021 and April 2022. Among them:

• 67% reported moderate to severe fatigue
• 22% reported severe fatigue
• 59% reported normal to mild sleep disturbances
• 41% reported moderate to severe sleep disturbances

Black people were at least 3 times more likely than White people to get sleep problems. Previous research shows that people of color are more likely to be infected with COVID and have severe cases requiring hospitalization, compared with White people.^[7]

Other things linked to a higher likelihood of sleep disturbances among people with long COVID were whether someone had been hospitalized for COVID, had severe anxiety, or had moderate to severe fatigue.

A recent Kaiser Family Foundation analysis reported that as of January 2023, 28% of people who ever had COVID also had long COVID.^[8] The CDC says the most common long COVID symptoms are fatigue, fever, respiratory and heart problems, neurological problems, digestive problems, and issues that worsen after physical or mental effort.

Implications for the Interprofessional Healthcare Team

• Sleep disturbances are common among patients with long COVID
• Asking patients with recent COVID-19 or long COVID about their sleep habits could help identify sleep disturbances in a timely manner
• Sleep problems were more common in people of color: asking these patients about their sleep health could help address some of the health inequities

BAD SLEEP CUTS YEARS OFF LIFE, BUT EXERCISE CAN SAVE US

The third article evaluated the positive impact of exercise in people with poor sleep.^[9] While both physical activity and good sleep habits have been linked to longevity,^[10] few studies have assessed the effects of regular exercise on survival in people with poor sleep habits. Notably, the current study used accelerometers to track physical activity and sleep -- an approach that could provide more objective results than self-reported data.

Exercise Matters: Survival Outcomes in People With Poor Sleep

Experts recommend that most adults get 7 to 9 hours of sleep a night. If your patient is among the roughly one third of people who sleep less (or more), regular exercise may help them dodge possible long-term health consequences such as heart disease and early death.

Plenty of research points to sleep and physical activity as crucial factors affecting life expectancy. Regular exercise can lengthen life, while too little or too much sleep may cut it short.^[10]

But evidence is growing that exercise may counteract the negative effects of poor sleep. A 2022 study found that being physically active for at least 25 minutes a day can erase the risk of early death associated with too much sleep or trouble falling asleep.^[11] And a 2021 study found that lower levels of physical activity may exacerbate the impact of poor sleep on early death, heart disease, and cancer.^[12]

The latest such study, published in the European Journal of Preventive Cardiology, suggests that higher volumes of exercise can virtually eliminate the risk of early death associated with sleeping too little or too long.^[9]

This study is unique, the researchers say, because it used accelerometers (motion-tracking sensors) to quantify sleep and physical activity. Other studies asked participants to report their own data, opening the door to false reports and mistakes.

Some 92,000 participants in the UK (mean age, 62 years; 56% women) wore the activity trackers for a week to measure how much they moved and slept. In the following 7 years, 3080 participants died, mostly from cardiovascular disease or cancer.

As one might expect, the participants who were least likely to die also exercised the most and slept the "normal" amount (6 to 8 hours a night, as defined by the study).

Compared to that group, those who exercised the least and slept < 6 hours were 2.5 times more likely to die during those 7 years (P < .001). Less active persons who got the recommended sleep were 79% more likely to die (P < .001). The risk was slightly higher than that for those who logged > 8 hours a night.

But those risks disappeared for short- or long-sleeping participants who logged at least 150 minutes a week of moderate to vigorous activity.

"Exercise fights inflammatory and metabolic dysregulations and abnormal sympathetic nervous system activity," said study author Jihui Zhang, PhD, of the Affiliated Brain Hospital of Guangzhou in China. Those problems are associated with cardiovascular diseases and other potentially fatal conditions.

More Objective Data -- With Tech

A study's findings are only as good as the data it relies on. That's why obtaining objective data, not influenced by individual perception, is key.

"Self-report questionnaires are prone to misperception, or recall or response bias," Zhang explains.

Take sleep, for example. Research reveals that several factors can affect how we judge our sleep. When people have to sleep at irregular times, they often underestimate how many hours they sleep but overestimate how long they nap, found a study in the Journal of Clinical Sleep Medicine.^[13]

Another study showed that when people are under a lot of stress, they'll report more sleep problems than they actually have, as revealed by an Actiheart monitor.^[14]

With exercise, participants often report doing more exercise, and doing it at a higher intensity, than objective measurements show they did.^[15] At the same time, self-reports typically don't account for much of the unplanned, low-effort movement people do throughout the day.^[16]

Staying Active When You're Tired

The study raises a practical question: If you don't get the proper amount of sleep, how are you supposed to find the time, energy, and motivation to exercise? The solution is to use one to fix the other.

Exercise and sleep have "a robust directional relationship," Zhang said. Exercise improves sleep, while better sleep makes it easier to stick with an exercise program.

Ideally, that program will include a mix of cardio and resistance exercise, said Mitch Duncan, PhD, a professor of public health at the University of Newcastle in Australia. As Duncan and his co-authors showed in a recent study,^[17] "the largest benefits to health occur when people do a combination of both aerobic and muscle-strengthening activity," Duncan said.

"In terms of benefits to sleep, there doesn't seem to be consistent evidence that favors either as being most effective." The timing or intensity of exercise doesn't seem to matter much, either.^[18] "But there is evidence that a greater duration contributes to larger improvements in sleep," Duncan said. In other words, longer workouts are generally better, but they don't necessarily have to be super-intense.

The strongest evidence of all, however, shows that recent and regular exercise offer the biggest benefits at bedtime.

Today's workout will improve tonight's sleep. And the better you sleep tonight, the more likely you are to stick with the program.

Implications for the Interprofessional Healthcare Team

• For patients with poor sleep habits, recommending regular exercise could improve sleep and other health outcomes
• Help motivate patients to stick to an exercise plan by focusing on persistence, rather than intensity or duration
• Consider the use of wearable devices to get an accurate assessment of the patient's activity level and sleep patterns

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