Chronic insomnia disorder as risk factor for stroke: a systematic review

Abstract

Background Stroke is one of the main causes of mortality worldwide. Nonetheless, there are still risk factors that have not been fully elucidated, such as chronic insomnia disorder.

Objective To evaluate the association between chronic insomnia disorder and the risk of stroke in adults, through a systematic review.

Methods Multiple studies available in the Embase, Lilacs, and Medline platforms were evaluated in English, Spanish, French, and Portuguese. The selection of papers was restricted to those that had investigated the association between chronic insomnia disorder and stroke in adults, regardless of gender or nationality, without a previous history of stroke. The data was extracted with the Cochrane Effective Practice and Organization of Care (EPOC) form. The risk of bias was evaluated by the EPOC Risk of bias tool.

Results A total of 138 articles were identified. After a detailed evaluation with the eligibility criteria, four articles were included in the present systematic review. Three of them recognized the association between chronic insomnia disorder and stroke. The comparative analysis was limited, since the studies used distinct insomnia classifications. Regarding the risk of bias, the analysis displayed an important risk in the selection and allocation of participants, besides the use of own insomnia diagnosis criteria, disrespecting chronology and factors indicated by already established classifications.

Conclusions There is not enough data to determine that chronic insomnia disorder is a risk factor for stroke. The present study points out the existence of a possible relationship between insomnia disorder and stroke, suggesting that further studies adopt standardized criteria and instruments.

RESUMO

Antecedentes O acidente vascular cerebral (AVC) é uma das maiores causas de mortalidade do mundo. Ainda assim, existem fatores de risco não identificados, como o transtorno de insônia crônica.

Objetivo Avaliar a associação entre distúrbio crônico de insônia e o risco de AVC em adultos, por meio de uma revisão sistemática.

Métodos Foram avaliados estudos publicados em inglês, espanhol, francês e português, disponíveis nas plataformas Embase, Lilacs e Medline. Os estudos incluídos foram aqueles que investigaram a associação entre transtorno de insônia crônica e AVC em adultos, sem restrição de gênero ou de nacionalidade, sem história prévia de AVC. Os dados foram extraídos baseados no formulário da Cochrane Effective Practice and Organisation of Care (EPOC, na sigla em inglês). O risco de viés foi avaliado por meio da ferramenta EPOC Risk of bias tool.

Resultados Foram identificados 138 artigos, entre os quais, após avaliação detalhada para os critérios de elegibilidade, 4 foram incluídos na revisão sistemática. Destes, três encontraram associação entre insônia e AVC. Contudo, a análise comparativa apresenta limitações, pois nenhum dos estudos utilizou uma classificação comum de insônia. Quanto à análise do risco de viés, os estudos demonstraram um importante risco de viés na seleção e na alocação de participantes, além de utilizarem critérios diagnósticos de insônia próprios, sem respeitar cronologia e fatores indicados por classificações já estabelecidas.

Conclusões Não existem dados suficientes para determinar que o transtorno crônico de insônia se configura como fator de risco para AVC. A análise aponta para a existência de uma possível relação, sugerindo-se para estudos posteriores o uso de critérios e instrumentos padronizados.

Keywords

Sleep Initiation and Maintenance Disorders - Risk Factors - Stroke - Sleep-Wake Disorders

Palavras-chave

Distúrbios do Início e da Manutenção do Sono - Fatores de Risco - Acidente Vascular Cerebral - Transtornos do Sono-Vigília

Authors' Contributions

LASS and MMA: study concept and design, drafted the manuscript; ALRP, LASS, MMA, VG: data analysis and interpretation; ALRP, VG: critical revision of the manuscript; ALRP: final approval of the manuscript.

Publikationsverlauf

Eingereicht: 16. März 2021

Angenommen: 12. Oktober 2021

Artikel online veröffentlicht:
28. Dezember 2022

• References

• 1 Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2016. Geneva: World Health Organization; 2018
• 2 Valery LFeigin, Grant Nguyen, Kelly Cercy, Catherine OJohnson, Tahiya Alam, Priyakumari GParmar. et al. Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016. N Engl J Med 2018; 379: 2429-2437
• 3 Goldstein LB, Adams R, Alberts MJ. et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Counil: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke 2006; 37 (06) 1583-633
• 4 Bonnet MH, Arand DL. 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep 1995; 18 (07) 581-588
• 5 Irwin MR, Wang M, Campomayor CO, Collado-Hidalgo A, Cole S. Sleep deprivation and activation of morning levels of cellular and genomic markers of inflammation. Arch Intern Med 2006; 166 (16) 1756-1762
• 6 Krystal AD, Sorscher AJ. Recognizing and managing insomnia in primary care and specialty settings. J Clin Psychiatry 2016; 77 (04) e471
• 7 Bacelar A. Insônia do diagnóstico ao tratamento: III Consenso Brasileiro de Insônia. 1ª Edição. São Paulo: Omnifarma; 2013
• 8 American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Westchester: American Academy of Sleep Medicine; 2014
• 9 Bertolazi AN. Tradução, adaptação cultural e validação de dois instrumentos de avaliação do sono: Escala de Sonolência de Epworth e Índice de Qualidade de Sono de Pittsburgh [Master's Thesis]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2008
• 10 Buysse D, Reynolds C, Monk T, Berman S, Kupfer D. The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research. Elselvier; 1988: 193-213
• 11 Johns MW. Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the epworth sleepiness scale: failure of the MSLT as a gold standard. J Sleep Res 2000; 9 (01) 5-11
• 12 Lindsay MP, Norrving B, Sacco RL, Brainin M, Hacke W, Martins S. et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2019. Int J Stroke 2019; 14 (08) 806-817
• 13 National Institute of Neurological Disorders and Stroke [Internet]. Bethesda: National Institute of Neurological Disorders and Stroke; 2011 NIH Stroke Scale. Available from: https://www.ninds.nih.gov/sites/default/files/NIH_Stroke_Scale_Booklet.pdf
• 14 Wilson JTL, Hareendran A, Grant M, Baird T, Schultz UGR, Muir KW. et al. Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke 2002; 33 (09) 2243-2246
• 15 Effective Practice and Organisation of Care (EPOC). Data collection form. EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2013 Available from: http://epoc.cochrane.org/epoc-specific-resources-review-authors
• 16 Zheng B, Yu C, Lv J, Guo Y, Bian Z, Zhou M. et al; China Kadoorie Biobank Collaborative Group. Insomnia symptoms and risk of cardiovascular diseases among 0.5 million adults: A 10-year cohort. Neurology 2019; 93 (23) e2110-e2120
• 17 Helbig AK, Stöckl D, Heier M, Ladwig KH, Meisinger C. Symptoms of insomnia and sleep duration and their association with incident strokes: Findings fromthe population-based MONICA/KORA Augsburg Cohort Study. PLoS One 2015; 10 (07) 1-18
• 18 Hsu CY, Chen YT, Chen MH, Huang CC, Chiang CH, Huang PH. et al. The Association Between Insomnia and Increased Future Cardiovascular Events: A Nationwide Population-Based Study. Psychosom Med 2015; 77 (07) 743-751
• 19 Wu MP, Lin HJ, Weng SF, Ho CH, Wang JJ, Hsu YW. Insomnia subtypes and the subsequent risks of stroke: report from a nationally representative cohort. Stroke 2014; 45 (05) 1349-1354
• 20 Jaussent I, Empana JP, Ancelin ML, Besset A, Helmer C, Tzourio C. et al. Insomnia, daytime sleepiness and cardio-cerebrovascular diseases in the elderly: a 6-year prospective study. PLoS One 2013; 8 (02) e56048
• 21 Zhang S, Chang C, Zhang J, Song B, Fang H, Xu Y. Correlation analysis of sleep quality and youth ischemic stroke. Behav Neurol 2014; 2014: 1-6
• 22 Eguchi K, Hoshide S, Ishikawa S, Shimada K, Kario K. Short sleep duration is an independent predictor of stroke events in elderly hypertensive patients. J Am Soc Hypertens 2010; 4 (05) 255-262
• 23 Chen JC, Brunner RL, Ren H, Wassertheil-Smoller S, Larson JC, Levine DW. et al. Sleep duration and risk of ischemic stroke in postmenopausal women. Stroke 2008; 39 (12) 3185-3192
• 24 He Q, Zhang P, Li G, Dai H, Shi J. The association between insomnia symptoms and risk of cardio-cerebral vascular events: A meta-analysis of prospective cohort studies. Eur J Prev Cardiol 2017; 24 (10) 1071-1082
• 25 American Psychiatry Association. Diagnostic and Statistical Manual of Mental disorders - DSM-5. 5th ed. Washington: American Psychiatric Association; 2013
• 26 Mollayeva T, Thurairajah P, Burton K, Mollayeva S, Shapiro CM, Colantonio A. The Pittsburgh sleep quality index as a screening tool for sleep dysfunction in clinical and non-clinical samples: A systematic review and meta-analysis. Sleep Med Rev 2016; 25: 52-73
• 27 Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosom Res 2002; 53 (03) 737-740
• 28 Johns MW. Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep 1992; 15 (04) 376-381
• 29 Spira AP, Beaudreau SA, Stone KL, Kezirian EJ, Lui LY, Redline S. et al. Reliability and validity of the Pittsburgh sleep quality index and the epworth sleepiness scale in older men. Journals Gerontol - Ser A Biol Sci Med Sci 2012; 67 A (04) 433-9
• 30 Soldatos CR, Dikeos DG, Paparrigopoulos TJ. Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria. J Psychosom Res 2000; 48 (06) 555-560
• 31 Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011; 34 (05) 601-608
• 32 Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circ Res 2017; 120 (03) 472-495
• 33 Ge B, Guo X. Short and long sleep durations are both associated with increased risk of stroke: a meta-analysis of observational studies. Int J Stroke 2015; 10 (02) 177-184
• 34 Bassetti CLA, Randerath W, Vignatelli L, Ferini-Strambi L, Brill A-K, Bonsignore MR. et al. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur Respir J 2020; 55 (04) 1901104