Association of Sleep Disturbances With Prevalent and Incident Motoric Cognitive Risk Syndrome in Community-Residing Older Adults
Abstract
Background and Objectives
There is growing evidence that sleep disturbances are associated with cognitive impairment risk, but their association with the incidence of motoric cognitive risk syndrome (MCR)—a predementia syndrome characterized by slow gait speed and cognitive complaints—is unknown. We aimed to examine the association of sleep disturbances, overall and specific subtypes, with (1) incident and (2) prevalent MCR in older adults.
Methods
Community-residing adults aged 65 years and older without dementia were recruited from population lists and included in Central Control of Mobility and Aging, a prospective cohort study, in Albert Einstein College of Medicine, Bronx, NY. We included participants with available data for MCR and Pittsburgh Sleep Quality Index (PSQI). MCR was defined as cognitive complaints reported on standardized questionnaires and slow gait speed as recorded on an electronic treadmill and was adjudicated at baseline and annual follow-up visits. Participants were divided into “good” sleepers (≤5) and “poor” sleepers (>5) based on an established PSQI cut score. Among participants without MCR at baseline, Cox proportional hazard models adjusted for (1) age, sex, and education and (2) further for comorbidity index, Geriatric Depression Scale score, and global cognitive score were used to examine the association of baseline sleep disturbances with MCR incidence. Association between poor sleep quality and prevalent MCR at baseline in the overall population was explored using multivariate logistic regression analysis.
Results
445 participants were included (56.9% women, mean age: 75.9 years [75.3; 76.5]). In MCR-free participants at baseline (n = 403), 36 developed incident MCR over a mean follow-up of 2.9 years. Poor sleepers had a higher risk of incident MCR (HR = 2.7 [1.2; 5.2]) compared with good sleepers, but this association was not significant after adjustment for depressive symptoms (adjusted hazard ratio [aHR] = 1.6 [0.7–3.4]). Among the 7 PSQI components, only sleep-related daytime dysfunction (excessive sleepiness and lower enthusiasm) showed a significant risk of MCR in fully adjusted models (aHR = 3.3 [1.5–7.4]). Prevalent MCR was not associated with poor sleep quality (OR [95% CI] = 1.1 [0.5–2.3]).
Discussion
Overall poor sleep quality was associated with incident MCR, but not with prevalent MCR. Specifically, older adults with sleep-related daytime dysfunction are at increased risk of developing MCR. Further studies are needed to validate mechanisms of this relationship.
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© 2024 American Academy of Neurology.
Publication History
Received: June 5, 2024
Accepted: September 10, 2024
Published online: November 6, 2024
Published in print: December 10, 2024
Disclosure
The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.
Study Funding
The Central Control of Mobility in Aging was supported by National Institute on Aging grants (R01 AG044007 and R01 AG03692101A1). The content is solely the responsibility of the authors.
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We appreciate Dr. Carpi's pertinent comment on our article1 and the reminder regarding the Pittsburgh Sleep Quality Index (PSQI). Indeed, the "daytime dysfunction" component of the PSQI is derived from 2 distinct questions: one related to difficulties staying awake and the other concerning the presence or absence of enthusiasm to accomplish tasks.2 We concur that these items, particularly the latter, may be influenced by depressive symptoms and, more broadly, by mood.
To address this, we adjusted for the Geriatric Depression Scale, which is validated for screening depressive symptoms in older adults.3,4 The association between PSQI daytime dysfunction and incident motoric cognitive risk (MCR) remained significant in the fully adjusted model.
However, a more precise analysis of individual PSQI items, rather than an analysis of its components, might have been helpful. Our study did not aim to conduct multiple analyses; instead, we recommend further studies to explore the association between sleep disturbances and incident MCR.
References:
Author disclosures are available upon request ([email protected]).
We thank Dr. Feng for the comments on our article.1 The definition of motoric cognitive risk syndrome (MCR) was developed to provide an easy-to-implement clinical assay to identify older patients at high risk for dementia without requiring neuropsychological tests or laboratory assays. MCR has many causes, and it is not unexpected that the symptomatology of MCR and CSVD overlap, as noted by Dr. Feng. However, we do not advocate including MRI as the initial screening step, as this will not be practical, efficient, or cost-effective in clinical settings. While MCR has demonstrated its value in identifying patients at high risk for dementia,2 notably in primary care,3 further steps are needed, such as conducting investigations to identify the etiology, including CSVD, to plan further management.
References:
Author disclosures are available upon request ([email protected]).
We thank Yang et al. for their comments on our paper,1 and for their suggestions for future research. We fully concur that the bidirectional association between depression, anxiety, and sleep disturbances could be further explored in future studies. We recommended further observational studies and the consideration of mediation analyses in our paper.1 The issue of residual and unmeasured confounding is a potential limitation in all cohort studies.2 As the role and nature of sleep disturbances in MCR is further elucidated, randomized clinical trials of sleep interventions in MCR patients can be designed to prove cause-and-effect relationships as well as prevent further cognitive decline.
References:
Author disclosures are available upon request ([email protected]).
I read with great interest the recent article by Leroy et al.1 investigating the prospective association between self-reported sleep quality and motoric cognitive risk syndrome (MCR). The authors appropriately focused on whether sleep disturbances are related to the prevalence and incidence of MCR, a predementia syndrome characterized by cognitive symptoms and impaired gait.2
However, the primary finding of a longitudinal association between sleep-related daytime dysfunction and incident MCR may warrant further scrutiny. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI),3 considering both the global score and individual component scores. While the daytime dysfunction component emerged as the sole significant predictor of MCR risk after adjustment, it is worth noting that this component score averages 2 items: one evaluating difficulty staying awake in routine situations (e.g., driving or eating) and another assessing low enthusiasm. Since the significant proportion of the variance in the daytime dysfunction score may be attributed to the latter item, which is more reflective of deflected mood than sleepiness, the observed association may be partially biased.
Given the importance of the relationship between sleepiness and cognitive decline, alternative PSQI scoring approaches, such as splitting the daytime dysfunction component into its constituent items,4 could yield more precise insights.
References:
Author disclosures are available upon request ([email protected]).
We read the recent article by Leroy et al.1 with great interest. As the global population ages, the burden of cognitive disorders, particularly among older adults, is increasing,2 with poor sleep quality strongly linked to cognitive decline.3,4 However, the role of sleep disturbances in motoric cognitive risk syndrome (MCR), a precursor to dementia, remains unclear. We appreciate the work by Leroy et al.1 which explores the relationship between sleep disturbances and MCR, highlighting daytime dysfunction as a potential early indicator. While the study significantly contributes to the field, some limitations persist, providing a basis for further analysis.
Firstly, despite adjusting for depressive symptoms, the bidirectional relationship between depression, anxiety, and sleep disturbances may still confound the link between sleep quality and MCR.
Secondly, unaccounted lifestyle factors such as diet, physical activity, and social support could introduce bias. Additionally, the failure to screen for early neurodegenerative diseases may exaggerate the association between sleep disturbances and MCR.
Lastly, not excluding participants with severe sleep disorders or long-term medication use may impact result accuracy.
Future research should control for emotional factors, incorporate lifestyle variables, and exclude participants with early neurodegenerative diseases or severe sleep disorders to better explore the relationship between sleep disturbances and MCR.
References:
Author disclosures are available upon request ([email protected]).
I read the recent article by Leroy et al. 1 with great interest. The study demonstrated that overall poor sleep quality was associated with incident motoric cognitive risk syndrome (MCR), but not with prevalent MCR. MCR is a predementia syndrome first described in 2013 that is characterized by the presence of cognitive symptoms and slow gait speed.1 However, it is difficult to differentiate MCR from cerebral small vessel disease (CSVD).
CSVD manifests with clinical symptoms such as cognitive impairment, gait disorder, autonomic dysfunction, and lesions such as white matter hyperintensity (WMH), lacunes, perivascular space (PVS), and microbleeds on neuroimaging.2 Gait abnormalities including slowing of speed.3 Magnetic resonance imaging (MRI) is an important method to evaluate the occurrence, development, and severity of CSVD;4 however, there was no MRI used in this study to rule out the possibility of CSVD.
References:
Author disclosures are available upon request ([email protected]).