Sleep & Brain Health Lab Free At-home Memory & Sleep Assessment

What is your first name?

What is your current age in years?

What is your sex?

Are you able to read, write, and understand English?

Are you a resident of Ontario?

Are you able to participate in video-based cognitive assessments (access to a computer or laptop or similar and a Zoom account)?

Would you be willing to attend an overnight sleep study at Sunnybrook Health Sciences Centre if the sleep assessment suggested you had high risk of a sleep disorder?

Would you be willing to use a CPAP machine if diagnosed with sleep apnea?

Have you ever been diagnosed with sleep apnea?

What year were you first diagnosed with sleep apnea?

Have you ever been treated for sleep apnea in the past year?

What type of treatment?

Please list "Other" treatment for sleep apnea?

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?

Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?

Do you have or are being treated for High Blood Pressure?

Is your shirt collar 16 inches/40cm or larger (measured around Adams apple)

What is your family doctor's name? If you do not have one, write "none"

What is your family doctor's phone number? If you do not have a family doctor, write "none"

What is your email address?

What is your phone number?

Where did you hear about this screening program?

If other, please let us know where you heard from us

Do you understand and consent to the following:

This form is in relation to the research study titled: EPIC SLEEP - Enabling Prevention of Impaired Cognition by SLEEP Education and CPAP: A Multi-Centre Randomized Controlled Trial. The purpose of this study is to find out what effects CPAP has on you and your cognitive function and AD-related brain changes and determining what is the best approach to delivering CPAP in combination with sleep educational interventions.

Taking part in this study is voluntary. You have the option to not participate at all.

All participants in this study will receive web-based sleep education for 8 months and CPAP for 4 or 8 months depending on which study group they are randomized.

We hope the information learned from this study will help other people with MCI and sleep apnea in the future. This study could support widespread treatment of sleep apnea in patients with MCI to slow cognitive decline and reduce AD-related brain changes, and identify how best to combine treatments (i.e. sleep education, CPAP) to achieve this.

By filling out this form, you are providing implied consent to be contacted by study staff to assess eligibility (called an "eligibility screen"), including but not limited to questions about medical health, assessment of memory and concentration, and assessment of sleep apnea.

The data in this form and any data collected when assessing eligibility will be kept confidential and, to the extent permitted by the applicable laws, will not be disclosed or made publicly available. Study doctors and study staff will only collect the information they need for this study.

Formal, full consent will be discussed and obtained only in those deemed eligible after the eligibility screen.

Should you have any additional questions prior to filling out this form you are encouraged to contact the study coordinator at 1-647-608-9833 or andrew.centen@sunnybrook.ca.

The principal investigator of this research study is Dr. Andrew Lim (416-480-6100 x5753) and the research ethics board (REB) for this study is the Sunnybrook Research Ethics Board (416-480-6100 x688144).