The influence of narcolepsy on olfactory function: a review

IntroductionNarcolepsy is a sleep disorder associated with loss of hypocretin cells characterized by irrepressible need to sleep, often accompanied by cataplexy, sleep fragmentation, hypnagogical and hypnopompic hallucinations, and sleep paralysis. It is also correlated with alterations in the sleep–wake cycle, dysautonomia, olfactory dysfunction, and eating disorders.MethodsThis is a review about influence of narcolepsy on human olfaction. Pubmed, Embase, Ovid and Cochrane databases were searched for articles on the evaluation of olfactory function in narcoleptic patients including terms as narcolepsy, olfaction disorder, amongst others.ResultsSeven articles met the inclusion criteria. In five of them, the olfaction of narcoleptic patients was diminished in comparison with healthy control groups. The diagnosis of narcolepsy relates to worse performance in olfactory tests.Experimental researches showed that hypocretin and hypocretin receptors are present in the olfactory system, and this neuropeptide may have a role on olfactory sensitivity and on the olfactory modulation. The cause of hyposmia appears to be multifactorial. Among them, it stands out the hypocretin deficiency, therefore, that seems to be involved in the olfactory impairment in narcoleptic patients.     

Deep brain stimulation of hypothalamus for narcolepsy-cataplexy in mice

BackgroundNarcolepsy type 1 (NT1, narcolepsy with cataplexy) is a disabling neurological disorder caused by loss of excitatory orexin neurons from the hypothalamus and is characterized by decreased motivation, sleep-wake fragmentation, intrusion of rapid-eye-movement sleep (REMS) during wake, and abrupt loss of muscle tone, called cataplexy, in response to sudden emotions.ObjectiveWe investigated whether subcortical stimulation, analogous to clinical deep brain stimulation (DBS), would ameliorate NT1 using a validated transgenic mouse model with postnatal orexin neuron degeneration.MethodsUsing implanted electrodes in freely behaving mice, the immediate and prolonged effects of DBS were determined upon behavior using continuous video-electroencephalogram-electromyogram (video/EEG/EMG) and locomotor activity, and neural activation in brain sections, using immunohistochemical labeling of the immediate early gene product c-Fos.ResultsBrief 10-s stimulation to the region of the lateral hypothalamus and zona incerta (LH/ZI) dose-responsively reversed established sleep and cataplexy episodes without negative sequelae. Continuous 3-h stimulation increased ambulation, improved sleep-wake consolidation, and ameliorated cataplexy. Brain c-Fos from mice sacrificed after 90 min of DBS revealed dose-responsive neural activation within wake-active nuclei of the basal forebrain, hypothalamus, thalamus, and ventral midbrain.ConclusionAcute and continuous LH/ZI DBS enhanced behavioral state control in a mouse model of NT1, supporting the feasibility of clinical DBS for NT1 and other sleep-wake disorders.     

Specificity of direct transition from wake to REM sleep in orexin/ataxin-3 transgenic narcoleptic mice

To create operational criteria for polygraphic assessments of direct transitions from wake to REM sleep (DREM), as a murine analog of human cataplexy, we have analyzed DREM episodes in congenic lines of orexin/ataxin-3 transgenic [TG] mice and wild-type littermates. The sleep stage of each 10-second epoch was visually scored using our standard criteria. Specificity of DREM for narcoleptic TG mice and sensitivity to detect DREM was evaluated using different DREM criteria. We found that DREM transitions by 10-second epoch scoring are not specific for narcoleptic TG mice and also occur in WT mice during light period. These wake-to-REM transitions in WT mice (also seen in TG mice during light period) were characteristically different from DREM transitions in TG mice during dark period; they tended to occur as brief bouts of wakefulness interrupting extended episodes of REM sleep, suggesting that these transitions do not represent abnormal manifestations of REM sleep. We therefore defined the DREM transitions by requiring a minimum number of preceding wake epochs. Requiring no fewer than four consecutive epochs of wakefulness produced the best combination of specificity (95.9%) and sensitivity (66.0%). By definition, DREM in dark-period is 100% specific to narcolepsy and was 95.9% specific overall. In addition, we found that desipramine, a trycyclic anticataplectic, potently reduces DREM, while two wake-promoting compounds have moderate (d-amphetamine) and no (modafinil) effect on DREM; the effects mirror the anticataplectic effects of these compounds reported in canine and human narcolepsy. Our definition of DREM in murine narcolepsy may provide good electrophysiological measures for cataplexy-equivalent episodes.     

Age-related insulin resistance in hypothalamus and peripheral tissues of orexin knockout mice

Aims/hypothesis Orexin/hypocretin is a hypothalamic neuropeptide that regulates motivated behaviours, such as feeding and arousal, and, importantly, is also involved in energy homeostasis. The aim of this study was to reveal the role of orexin in the regulation of insulin sensitivity for glucose metabolism. Methods Orexin knockout mice fasted overnight underwent oral glucose tolerance testing and insulin tolerance testing. The impact of orexin deficiency on insulin signalling was studied by Western blotting to measure levels of Akt phosphorylation and its upstream and downstream molecules in the hypothalamus, muscle and liver in orexin knockout mice. Results We found that orexin deficiency caused the age-related development of impaired glucose tolerance and insulin resistance in both male mice without obesity and female mice with mild obesity, fed a normal chow diet. When maintained on a high-fat diet, these abnormalities became more pronounced exclusively in female orexin knockout mice that developed severe obesity. Insulin signalling through Akt was disrupted in peripheral tissues of middle-aged (9-month-old) but not young adult (2-to-3-month-old) orexin knockout mice fed a normal chow diet. Moreover, basal levels of hypothalamic Akt phosphorylation were abnormally elevated in orexin knockout mice at every age studied, and insulin stimulation failed to increase the level of phosphorylation. Similar abnormalities were observed with respect to GSK3β phosphorylation in the hypothalamus and peripheral tissues of middle-aged orexin knockout mice. Conclusions/interpretation Our results demonstrate a novel role for orexin in hypothalamic insulin signalling, which is likely to be responsible for preventing the development of peripheral insulin resistance with age. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

The ICSD-3 and DSM-5 guidelines for diagnosing narcolepsy: clinical relevance and practicality

Narcolepsy is a chronic neurological disease manifesting as difficulty with maintaining continuous wake and sleep. Clinical presentation varies but requires excessive daytime sleepiness (EDS) occurring alone or together with features of rapid-eye movement (REM) sleep dissociation (e.g., cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis), and disrupted nighttime sleep. Narcolepsy with cataplexy is associated with reductions of cerebrospinal fluid (CSF) hypocretin due to destruction of hypocretin peptide-producing neurons in the hypothalamus in individuals with a specific genetic predisposition. Updated diagnostic criteria include the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and International Classification of Sleep Disorders Third Edition (ICSD-3). DSM-5 criteria require EDS in association with any one of the following: (1) cataplexy; (2) CSF hypocretin deficiency; (3) REM sleep latency ≤15?minutes on nocturnal polysomnography (PSG); or (4) mean sleep latency ≤8?minutes on multiple sleep latency testing (MSLT) with ≥2 sleep-onset REM-sleep periods (SOREMPs). ICSD-3 relies more upon objective data in addition to EDS, somewhat complicating the diagnostic criteria: 1) cataplexy and either positive MSLT/PSG findings or CSF hypocretin deficiency; (2) MSLT criteria similar to DSM-5 except that a SOREMP on PSG may count as one of the SOREMPs required on MSLT; and (3) distinct division of narcolepsy into type 1, which requires the presence of cataplexy or documented CSF hypocretin deficiency, and type 2, where cataplexy is absent, and CSF hypocretin levels are either normal or undocumented. We discuss limitations of these criteria such as variability in clinical presentation of cataplexy, particularly when cataplexy may be ambiguous, as well as by age; multiple and/or invasive CSF diagnostic test requirements; and lack of normative diagnostic test data (e.g., MSLT) in certain populations. While ICSD-3 criteria reflect narcolepsy pathophysiology, DSM-5 criteria have greater clinical practicality, suggesting that valid and reliable biomarkers to help standardize narcolepsy diagnosis would be welcomed.     

Age-related changes in hypocretin (orexin) immunoreactivity in the cat brainstem

Terminals of hypothalamic hypocretin-containing neurons are observed within brainstem nuclei involved in the control of sleep and wakefulness. Because aged humans, cats and other species exhibit changes in sleep and wakefulness in old age, we were interested in examining age-related changes in hypocretin/orexin projections to the following brainstem regions which are associated with the regulation of sleep and wakefulness: the dorsal raphe nucleus, the laterodorsal tegmental nucleus, the pedunculo-pontine tegmental nucleus and the locus coeruleus. Based upon the results of immunohistochemical determinations, in all the regions examined, round or oval ‘spot-like’ structures were observed in aged cats. Many of these ‘spot-like’ structures resembled enlarged varicosities of a nature that would be expected to disrupt hypocretin neurotransmission. In addition, a site-specific decrease in immunostaining was observed in the locus coeruleus in old cats compared with adult controls; this result likely reflects a decrease in the number of labeled fibers, which indicates that there occurs a degeneration of hypocretinergic function in conjunction with old age. The proceeding changes may account for some of sleep–wake disturbance which are observed in aged animals as well as elderly humans.     

Orexin-A acts on the paraventricular nucleus of the midline thalamus to inhibit locomotor activity in rats

Orexins (hypocretins) are novel peptides that have been shown to play a role in control of behavioral arousal. The paraventricular nucleus of the midline thalamus (PVT) is one area of the brain that is the most densely innervated by orexin fibers. In addition, the PVT sends a dense projection to the nucleus accumbens, an area of the striatum involved in the regulation of locomotion. This study was done to determine the effect of microinjections of orexin-A (OXA) or the orexin receptor antagonist SB334867 in the PVT on locomotor activity (LA) in morphine-naïve and morphine-sensitized rats. Microinjections of OXA (3 μg/500 nl) in or near the PVT inhibited LA in rats tested in a novel and familiar environment as well as in rats expressing behavioral sensitization to repeated injections of morphine. In contrast, microinjections of SB334867 had no effect on LA in any of the test situations. Using an approach involving experimenter based analysis of ethological behaviors; we found that microinjections of OXA in the midline thalamus decreased LA while at the same time increasing the expression of grooming and freezing. These results suggest that OXA can act on the PVT and the midline thalamus to produce arousal independent of LA.     

Integration of feeding and spontaneous physical activity: role for orexin

Spontaneous physical activity is activity that is non-volitional, or subconscious, such as fidgeting and shifting in one's seat, and time spent moving (standing and ambulating). Recent evidence indicates that spontaneous physical activity, and the resulting thermogenesis (non-exercise activity thermogenesis) may be regulated by brain systems. A large number of brain areas, with their associated neurotransmitter populations and connectivity, participate in the regulation of feeding behavior by acting as energy sensing and modulating centers. Although less well characterized, it is likely that a multitude of neurotransmitters and brain areas act to mediate spontaneous physical activity. These two behaviors, feeding and spontaneous physical activity, affect energy intake and expenditure and thus are important to body weight. Interestingly, often the two behaviors are affected simultaneously; when feeding is affected, so too is spontaneous physical activity, and both food intake and physical activity (whether spontaneous or volitional) influence activity of brain areas important to both. Several brain areas and neuropeptides are important to feeding and spontaneous physical activity. The lateral hypothalamus is one area that appears important to both behaviors, as stimulation or lesion of this region produces alterations in feeding behavior and spontaneous physical activity. Orexin neurons, with their central location in the lateral hypothalamus, widespread projections and connectivity to other brain areas important to energy homeostasis, are well situated to perform an integrative function. This review focuses on how hypothalamic orexins participate in both feeding and spontaneous physical activity, and provides potential models for the integration of signals important to both.     

The wake-promoting effects of hypocretin-1 are attenuated in old rats

Disruption of sleep is a frequent complaint among elderly humans and is also evident in aged laboratory rodents. The neurobiological bases of age-related sleep/wake disruption are unknown. Given the critical role of the hypocretins in sleep/wake regulation, we sought to determine whether the wake-promoting effect of hypocretin changes with age in Wistar rats, a strain in which age-related changes in both sleep and hypocretin signaling have been reported. Intracerebroventricular infusions of hypocretin-1 (10 and 30 μg) significantly increased wake time relative to vehicle in both young (3 mos) and old (25 mos) Wistar rats. However, the magnitude and duration of the wake-promoting effects were attenuated with age. An increase of parameters associated with homeostatic sleep recovery after sleep deprivation, including non-rapid eye movement (NR) sleep time, NR delta power, the ratio of NR to rapid eye movement (REM) sleep, and NR consolidation, occurred subsequent to Hcrt-induced waking in young but not old rats. ICV infusions of hypocretin-2 (10 and 30 μg) produced fewer effects in both young and old rats. These data demonstrate that activation of a major sleep/wake regulatory pathway is attenuated in old rats.     

Orexin in sleep,addiction and more: Is the perfect insomnia drug at hand?

Orexins A and B (hypocretins 1 and 2) and their two receptors (OX₁R and OX₂R) were discovered in 1998 by two different groups. Orexin A and B are derived from the differential processing of a common precursor, the prepro-orexin peptide. The neuropeptides are expressed in a few thousand cells located in the lateral hypothalamus (LH), but their projections and receptor distribution are widespread throughout the brain. Remarkably, prepro peptide and double (OX₁R/OX₂R) receptor knock out (KO) mice reproduce a sleep phenotype known in humans and dogs as narcolepsy/cataplexy. In humans, this disease is characterized by the absence of orexin producing cells in the LH, and severely depleted levels of orexin the cerebrospinal fluid. Null mutation of the individual OX₁R or OX₂R in mice substantially ameliorates the narcolepsy/cataplexy phenotype compared to the OX₁R/OX₂R KO, and highlights specific roles of the individual receptors in sleep architecture, the OX₁R KO demonstrating an a attenuated sleep phenotype relative to the OX₂R KO. It has therefore been suggested that orexin is a master regulator of the sleep-wake cycle, with high activity of the LH orexin cells during wake and almost none during sleep. Less than 10 years later, the first orexin antagonist, almorexant, a dual orexin receptor antagonist (DORA), was reported to be effective in inducing sleep in volunteers and insomnia patients. Although development was stopped for almorexant and for Glaxo’s DORA SB-649868, no less than 4 orexin receptor antagonists have reached phase II for insomnia, including Filorexant (MK-6096) and Suvorexant (MK-4305) from Merck. Suvorexant has since progressed to Phase III and dossier submission to the FDA. These four compounds are reported as DORAs, however, they equilibrate very slowly at one and/or the other orexin receptor, and thus at equilibrium may show more or less selectivity for OX₁R or OX₂R. The appropriate balance of antagonism of the two receptors for sleep is a point of debate, although in rodent models OX₂R antagonism alone appears sufficient to induce sleep, whereas OX₁R antagonism is largely devoid of this effect. Orexin is involved in a number of other functions including reward and feeding, where OX₁R (possibly OX₂R) antagonists display anti-addictive properties in rodent models of alcohol, smoking, and drug self-administration. However, despite early findings in feeding and appetite control, orexin receptor antagonists have not produced the anticipated effects in models of increased food intake or obesity in rodents, nor have they shown marked effects on weight in the existing clinical trials. The role of orexin in a number of other domains such as pain, mood, anxiety, migraine and neurodegenerative diseases is an active area of research. The progress of the orexin field is thus extraordinary, and the community awaits the clinical testing of more receptor selective antagonists in sleep and other disorders, as well as that of orexin agonists, with the latter expected to produce positive outcomes in narcolepsy/cataplexy and other conditions.