The behavioral morbidity of obstructive sleep apnea

doi:10.1053/pcad.1999.0410341

Progress in Cardiovascular Diseases

Volume 41, Issue 5, April 1999, Pages 341-354

https://doi.org/10.1053/pcad.1999.0410341 Get rights and content

Abstract

The behavioral morbidity associated with obstructive sleep apnea (OSA) includes symptoms of excessive daytime sleepiness (EDS), neurocognitive deficits, psychological problems, and possibly an increased chance of accidents. EDS is among the most frequently reported symptoms in patients diagnosed with OSA. The available data suggest that the primary cause of EDS is sleep fragmentation. The subjective measures of sleepiness include the sleep wake activity inventory and the epworth sleepiness scale. Sleepiness can also be evaluated objectively in the sleep laboratory using the multiple sleep latency test or the maintenance of wakefulness test. The neurocognitive manifestations of OSA include impairments in vigilance, concentration, memory, and executive function. There is no agreed on consensus as to how to best quantify neurocognitive deficits in this population. Symptoms consistent with depression or personality changes have also been described, but are likely to be correlates of EDS and/or the chronicity of the disorder. Manifestations of the behavioral morbidity of OSA are reversible, but dependent on the degree of normalization in sleep-disordered breathing and the individual's sleep habits. Copyright © 1999 by W.B. Saunders Company

Progress in Cardiovascular Diseases, Vol. 41, No. 5 (March/April), 1999: pp 341-354

Section snippets

Excessive daytime sleepiness

EDS is conceptualized as the heightened propensity to fall asleep while involved in activities that require alertness. It is important to understand that EDS accumulates over time. Initially, affected individuals may only experience sleepiness during the middle of the day, which coincides with one of two peaks in the natural biphasic propensity to fall asleep.¹ For patients with OSA, however, EDS may become a chronic experience. The symptoms can not be modulated by extending the amount of

Neurocognitive testing

The mechanism behind neurocognitive deficits in OSA patients is not clearly understood. Many believe that hypoxemia and its biochemical and hemodynamic effects on the central nervous system (CNS) are responsible for impairments found in apneics.[18], [19] Yet others attribute the neurocognitive deficits to EDS.[43], [44], [45] Regardless of causal factors involved, multiple reports in the literature document these deficits in OSA patients. The tests that have been used to assess neurocognitive

Psychosocial impact of OSA

The chronic nature of OSA as well as the actual symptoms accompanying the behavioral morbidity of the disorder, have a significant impact on the patients social, emotional, and psychological well-being. Clinical experience and surveys of this population suggest that problems in the psychosocial life of apneics are the result, not the cause, of the symptoms of OSA.

Kales et al surveyed 50 consecutive severe OSA patients and 80 age and sex-matched controls.⁶³ All patients were required to complete

The reversal of the behavioral morbidity with treatment of OSA

CPAP has become the treatment of choice for moderate and severe OSA patients. CPAP normalizes sleep-disordered breathing and thereby reverses the effects of OSA on sleep fragmentation, hypoxemia, and sleep architecture. Compared with surgical treatment via uvulopalatopharyngoplasty, CPAP renders a more consistent and predictable improvement of sleep disordered breathing.²³ However, the effects of CPAP on the reversal of the behavioral morbidity in this population have been controversial. A

Conclusion

The occurrence of repetitive respiratory events during sleep provoke profound changes in the normal physiology of the individual. These changes have both acute and chronic consequences. Sufferers may be exposed to recurrent hypoxemic episodes and pleural pressure swings that create significant ventilatory stress, sleep fragmentation, and the disruption of the homeostatic nature of sleep. From a hemodynamic perspective the changes are also known to be significant, and result in a complex

References (81)

L Rosenthal et al.
The sleep-wake activity inventory: A self-report measure of daytime sleepiness
Biol Psychiatry
(1993)
R Chervin et al.
Comparison of the results of the epworth sleepiness scale and the multiple sleep latency test
J Psychosom Res
(1997)
L Rosenthal et al.
The sleep/wake habits of patients diagnosed as having obstructive sleep apnea
Chest
(1997)
L Findley et al.
Cognitive impairment in patients with obstructive sleep apnea and associated hypoxemia
Chest
(1986)
W Orr et al.
Hypersomnolent and nonhypersomnolent patients with upper airway obstruction during sleep
Chest
(1979)
H Colt et al.
Hypoxemia vs sleep fragmentation as cause of excessive daytime sleepiness in obstructive sleep apnea
Chest
(1991)
T Roehrs et al.
Predictors of objective level of daytime sleepiness in patients with sleep-related breathing disorders
Chest
(1989)
C Guilleminault et al.
A cause of excessive daytime sleepiness: The upper airway resistance syndrome
Chest
(1993)
D Nagel
Human error in aviation operations
A McCartt et al.
The scope and nature of the drowsy driving problem in New York State
Acid Anal Prev
(1996)

K Doghramji

Maintenance of wakefulness test

M Carskadon et al.

The multiple sleep latency test: What does it measure?

Sleep

(1982)

C Reynolds et al.

Depressive psychopathology in male sleep apneics

J Clin Psychiatry

(1984)

C Feuerstein et al.

Frontal lobe-related cognitive functions in patients with sleep apnea syndrome before and after treatment

Acta Neurol Belg

(1997)

K Chesire et al.

Factors impairing daytime performance in patients with sleep apnea/hypopnea syndrome

Arch Intern Med

(1992)

F Zorick et al.

Effects of uvulopalatopharyngoplasty on daytime sleepiness associated with sleep apnea syndrome

Bull Eur Physiopathol Respir

(1983)

F Zorick et al.

Response to CPAP and UPPP in Apnea

Henry Ford Med J

(1990)

A Gold et al.

The effect of nocturnal oxygen administration upon sleep apnea

Am Rev Respir Dis

(1986)

C Guilleminault et al.

Sleep apnea syndromes and related sleep disorders

Cited by (65)

Normal multiple sleep latency test values in adults: A systematic review and meta-analysis
2023, Sleep Medicine
Sleep latency is a measure of time it takes to enter sleep. Very short sleep latencies are indicative of excessive daytime sleepiness and pathological sleep conditions such as narcolepsy. The normal range of mean sleep latency calculated from the multiple sleep latency test in healthy adults is not well-established. We provide a review of normative mean sleep latency values on the multiple sleep latency test by synthesizing data from 110 healthy adult cohorts. We also examine the impact of demographic variables such as age, sex, body mass index, sleep architecture and sleep-disordered breathing as well as methodological variables such as sleep onset definitions and multiple sleep latency test protocols. The average mean sleep latency was 11.7 min (95% CI: 10.8–12.6; 95% PI: 5.2–18.2) for cohorts evaluated using the earlier definition of sleep onset and 11.8 min (95% CI: 10.7–12.8; 95% PI: 7.2–16.3) for those evaluated using the later definition. There were no significant associations between mean sleep latency and demographic or methodological variables. A negative association of −0.29 per one unit increase (95% CI: −0.55 to −0.04) was found between mean sleep latency and apnea-hypopnea index on prior night polysomnography. Establishing updated ranges for mean sleep latency among healthy adults may guide clinical decision-making surrounding sleep pathologies and inform future research into the associations between patient variables, daytime sleepiness, and sleep pathologies.
Determinants of policy decisions for non-commercial drivers with OSA: An integrative review
2018, Sleep Medicine Reviews
Citation Excerpt :
Also related to OSA are health risks such as hypertension and obesity, or illnesses such as diabetes and cardiovascular disorders [3–7]. Of particular relevance to driving, excessive daytime sleepiness secondary to OSA has been identified as an important health-related risk in commercial transportation [8–13] with, possibly, an increased chance of road accidents due to impairments in vigilance, concentration, memory, and executive function [14]. The objective of the present review is to summarize the state of knowledge about OSA and risk-related driving behavior among non-commercial drivers.
Excessive daytime sleepiness and reduced cognitive functioning secondary to obstructive sleep apnea (OSA) have been identified as an important health-related risk in commercial transportation with, possibly, an increased chance of road accidents. This has resulted in a variety of policies and restrictions imposed on commercial drivers. Here we review current knowledge to assess whether available data are sufficient to guide policy decisions concerning restrictions for non-commercial drivers. The review shows that there is a lack of uniformity among different consensus conferences and guidelines as to how to deal with drivers with OSA. Clear guidelines are limited and few are evidence based. It is unclear which aspect of OSA is the most valid measure of severity (e.g., apnea–hypopnea index vs oxygen desaturation index). Traditionally, sleepiness has been invoked as a major risk factor for impaired driving. Recently, there also has been an awareness that daytime fatigue, as distinct from sleepiness, has an impact on driving behavior. However, the precise effect of fatigue on driving, as well as its role in the formulation of guidelines, remain to be evaluated. We conclude that there are at least two major difficulties for the driving recommendation process: a) there is no accurate metric quantifying severity of driving risk associated with OSA, and b) there are substantial individual differences among those with OSA, both experiential and behavioral. We present implications from this review for future research and policy formulation.
Sleep disruption increases seizure susceptibility: Behavioral and EEG evaluation of an experimental model of sleep apnea
2016, Physiology and Behavior
Citation Excerpt :
Sleep is a vital, natural, periodic and reversible physiological state of decreased vigilance. Therefore, changes in sleep duration and architecture are associated with different diseases, including cardiovascular diseases, neurological disorders, psychosis, bipolar disorder, as well as epilepsy [1]. Sleep deprivation has been identified as one of the leading precipitant factors in patients with epilepsy [2].
Sleep disruption accompanies sleep apnea as one of its major symptoms. Obstructive sleep apnea is particularly common in patients with refractory epilepsy, but causing factors underlying this are far from being resolved. Therefore, translational studies regarding this issue are important. Our aim was to investigate the effects of sleep disruption on seizure susceptibility of rats using experimental model of lindane-induced refractory seizures.
Sleep disruption in male Wistar rats with implanted EEG electrodes was achieved by treadmill method (belt speed set on 0.02 m/s for working and 0.00 m/s for stop mode, respectively). Animals were assigned to experimental conditions lasting 6 h: 1) sleep disruption (sleep interrupted, SI; 30 s working and 90 s stop mode every 2 min; 180 cycles in total); 2) activity control (AC, 10 min working and 30 min stop mode, 9 cycles in total); 3) treadmill chamber control (TC, only stop mode). Afterwards, the animals were intraperitoneally treated with lindane (L, 4 mg/kg, SI + L, AC + L and TC + L groups) or dimethylsulfoxide (DMSO, SIc, ACc and TCc groups). Convulsive behavior was assessed by seizure incidence, latency time to first seizure, and its severity during 30 min after drug administration. Number and duration of ictal periods were determined in recorded EEGs.
Incidence and severity of lindane-induced seizures were significantly increased, latency time significantly decreased in animals undergoing sleep disruption (SI + L group) compared with the animals from TC + L. Seizure latency was also significantly decreased in SI + L compared to AC + L groups. Number of ictal periods were increased and duration of it presented tendency to increase in SI + L comparing to AC + L. No convulsive signs were observed in TCc, ACc and SIc groups, as well as no ictal periods in EEG.
These results indicate sleep disruption facilitates induction of epileptic activity in rodent model of lindane-epilepsy enabling translational research of this phenomenon.
" Listening for his breath:" The significance of gender and partner reporting on the diagnosis, management, and treatment of obstructive sleep apnea
2013, Social Science and Medicine
Citation Excerpt :
There may be decreased cognitive ability, impaired memory, and loss of interest in sex. Over the long-term, apnea is associated with more severe health problems, such as increased risk of traffic or industrial accidents, depression, high blood pressure, stroke, cardiac arrhythmias, and heart failure (Day, Gerhardstein, Lumley, Roth, & Rosenthal, 1999; Findley, Unverzagt, & Suratt, 1988; Yaggi et al., 2005). Population based studies indicate a prevalence range of obstructive sleep apnea syndrome in adults at between 2 and 5% in the general population, though 20% of the adult population may have at least mild sleep apnea symptoms (Young, Peppard, & Gottlieb, 2002).
In the elicitation of explanatory models for illnesses, accounts of spouses are strangely absent. This becomes critically missing information for a disorder like sleep apnea, in which a spouse or partner is often the primary agent responsible for the initial diagnosis and push to seek medical care. An apnea patient's understanding of their own illness is critically shaped less by their own direct experience of symptoms, and more by how someone else comes to experience, understand, and interpret them. Men and women, patients and partners, can vary tremendously in their decisions as to if, when, and how to either seek care for themselves, or to influence a partner to seek care. This cross-sectional, exploratory, mixed-methods study from the Dallas metropolitan area, USA, was done in 2006 to illuminate the significance of gender and partner-reporting in shaping the lay diagnosis, management, and treatment of obstructive sleep apnea. Patients clinically diagnosed with sleep apnea were recruited by a physician; a medical anthropologist then arranged in-depth, semi-structured interviews with both patients and partners (n = 24). Communication within relationships, along with social and cultural norms and expectations surrounding “proper” sleep for men and women, played important roles in how apnea was recognized, accepted, and acted upon by patients. More than half of men and women (patients or spouses) mention dissatisfaction with “positive airway pressure” machines, the primary treatment for obstructive apnea; partial compliance with medical advice was high, with dissatisfaction being patterned by gender. The medical anthropology of sleep disorders offers insight into traditional gender roles surrounding expected sleep and “proper” sleep roles. Given the small proportion of adults with apnea that currently see a physician for care, an expanded explanatory model involving spouses or partners promises to reveal new insight into patient behavior surrounding diagnosis, management, and treatment.
Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy
2011, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Numerous published studies have demonstrated a clear association between SDB and neurocognitive deficits, such as poor memory, difficulty learning, and reduced problem solving ability [1–3]. Behavioral changes such as aggression, hyperactivity, attention-deficit disorder, and poor socialization have also been tied to SDB [4–6]. At its extreme, sleep-disordered breathing can also lead to physical problems stemming primarily from poor ventilation.
To review our experience with intracapsular tonsillectomy using powered instrumentation (PIT) in the management of tonsillar hypertrophy.
Retrospective database review of pediatric patients undergoing PIT.
The medical records of 636 patients under 11 years of age who underwent PIT performed by the senior author (RFW), predominantly for obstructive sleep disturbance, were reviewed. Data were subsequently analyzed from 559 of these patients for clinical evidence of tonsillar regrowth, post-operative tonsillar hemorrhage, and post-operative dehydration due to pain. Specific information for possible correlation of age at the time of surgery and any increased rate of regrowth was primarily examined.
There were a total of 33 patients who had clinical evidence of regrowth. Children less than 5 years of age had 5 times the incidence of regrowth (p < 0.001). Out of the group that exhibited regrowth, 5 patients exhibited evidence of recurrent upper airway obstruction and underwent a complete tonsillectomy. The age of this complete tonsillectomy group ranged from 1.1 to 2.7 years. Out of all patients undergoing PIT, there was 1 incident of delayed post-operative dehydration due to emesis but not due to pain. There were 2 incidents of delayed post-operative tonsillar bleeds. All three complications were self-limited and did not require re-hospitalization.
PIT is a safe procedure with a small risk of tonsillar regrowth being age related. The incidence of postoperative complications following PIT is relatively low (0.54%).
Signs and symptoms of obstructive sleep apnea and upper airway resistance syndrome
2009, Sleep Apnea and Snoring

View all citing articles on Scopus

View full text

The behavioral morbidity of obstructive sleep apnea

Abstract

Section snippets

Excessive daytime sleepiness

Neurocognitive testing

Psychosocial impact of OSA

The reversal of the behavioral morbidity with treatment of OSA

Conclusion

Biol Psychiatry

J Psychosom Res

Chest

Chest

Chest

Chest

Chest

Chest

Acid Anal Prev

Chest

Chest

Chest

J Verb Learn Verb Behav

Cortex

J Chron Dis

Chest

Chest

Chest

Sleep Medicine Review

Circadian variation of sleep tendency in elderly and young adult subjects

Sleep

Automobile accidents involving patients with obstructive sleep apnea

Am Rev Respir Dis

Traffic accidents in commercial long-haul truck drivers: The influence of sleep-disordered breathing and obesity

Sleep

Self-reported automobile accidents involving patients with obstructive sleep apnea

Neurology

A new method for measuring daytime sleepiness: The epworth sleepiness scale

Sleep

Reliability and factor analysis of the epworth sleepiness scale

Sleep

The measurement of sleepiness in a sleep apnea population

Sleep Res

Daytime sleepiness: An epidemiological study of young adults

Am J of Public Health

A factor replication of the sleep-wake activity inventory (SWAI) in a Mexican population

Sleep

Guidelines for the multiple sleep latency test (MSLT): A standard measure of sleepiness

Sleep

Multiple sleep latency test: Technical aspects and normal values

J of Clin Neurophysiol

Maintenance of wakefulness test

The multiple sleep latency test: What does it measure?

Sleep

Depressive psychopathology in male sleep apneics

J Clin Psychiatry

Frontal lobe-related cognitive functions in patients with sleep apnea syndrome before and after treatment

Acta Neurol Belg

Factors impairing daytime performance in patients with sleep apnea/hypopnea syndrome

Arch Intern Med

Effects of uvulopalatopharyngoplasty on daytime sleepiness associated with sleep apnea syndrome

Bull Eur Physiopathol Respir

Response to CPAP and UPPP in Apnea

Henry Ford Med J

The effect of nocturnal oxygen administration upon sleep apnea

Am Rev Respir Dis

Sleep apnea syndromes and related sleep disorders