Sleep Apnea: Sleep Apnea: Neuropsychological Effects, Neuropsychological Effects, Research, and Treatment.Research, and Treatment.

By: Brooke Schauder, PhDBy: Brooke Schauder, PhD

Erie Psychological ConsortiumErie Psychological Consortium

Pacific Graduate School of Pacific Graduate School of PsychologyPsychology

What is Apnea?What is Apnea?►Sleep Apnea: Absence of breathing for 10 Sleep Apnea: Absence of breathing for 10

seconds during sleep, either due to seconds during sleep, either due to obstruction, central, or mixed. Obstructive obstruction, central, or mixed. Obstructive is by far the most common form.is by far the most common form.

►Obstructive Sleep Apnea: 1Obstructive Sleep Apnea: 1stst described in described in 1965, characterized by recurrent 1965, characterized by recurrent interruptions of breathing during sleep due interruptions of breathing during sleep due to temporary obstruction of the airway by to temporary obstruction of the airway by tissues (soft palate, uvula, or tonsils) with tissues (soft palate, uvula, or tonsils) with resultant hypoxemia and chronic lethargy.resultant hypoxemia and chronic lethargy.

►Hypoxia: Decrease below normal Hypoxia: Decrease below normal levels of oxygen in inspired gases, levels of oxygen in inspired gases, arterial blood, or tissue. arterial blood, or tissue.

►Normal oxygen hemoglobin saturation Normal oxygen hemoglobin saturation is approximately 95%. Decreases up to is approximately 95%. Decreases up to 50% during apneic episodes50% during apneic episodes

►Anoxia: Absence or almost complete Anoxia: Absence or almost complete absence of oxygen in inspired gases, absence of oxygen in inspired gases, arterial blood, or tissue. arterial blood, or tissue.

Sleep Stages and ApneaSleep Stages and Apnea

►During REM motor tone is at lowest level.During REM motor tone is at lowest level.►Collapse of upper airway.Collapse of upper airway.►Accessory muscles of respiration are Accessory muscles of respiration are

effectively paralyzed in REM. Diaphragm effectively paralyzed in REM. Diaphragm is solely responsible for breathing.is solely responsible for breathing.

►Typically worse at the end of the night, Typically worse at the end of the night, during longer stages of REM sleep & during longer stages of REM sleep & stages 3-4. stages 3-4.

Sleep Apnea SymptomsSleep Apnea Symptoms► Loud snoringLoud snoring► Gasping for air with Gasping for air with

complete or partial complete or partial wakingwaking

► Profuse sweatingProfuse sweating► Nightmares or night-Nightmares or night-

terrorsterrors► Enuresis (in children)Enuresis (in children)► Nocturnal Nocturnal

restlessnessrestlessness► Daytime sleepinessDaytime sleepiness► Morning HeadacheMorning Headache

► Apneic episodes Apneic episodes typically last 10-120 typically last 10-120 seconds.seconds.

► Episodes may be Episodes may be recurrent – 1 to 100 recurrent – 1 to 100 times throughout times throughout the night.the night.

DemographicsDemographics

►Affects 4% of men and 2% of women Affects 4% of men and 2% of women between ages 30 and 60. between ages 30 and 60.

►Mainly affects middle-aged adults.Mainly affects middle-aged adults.►““Typical” patient is overweight adult Typical” patient is overweight adult

male.male.►Up to 88% of adults patients estimated to Up to 88% of adults patients estimated to

be overweight.be overweight.► Incidence increases with advancing age. Incidence increases with advancing age. ►1% to 3% of children are affected 1% to 3% of children are affected

Risk FactorsRisk Factors

►ObesityObesity►HypothyroidismHypothyroidism►Cigarette SmokingCigarette Smoking►Alcohol useAlcohol use►Hypnotics use (benzodiazepines)Hypnotics use (benzodiazepines)

Recognizing Sleep ApneaRecognizing Sleep Apnea

►Consider diagnosis if patient snores Consider diagnosis if patient snores AND any of the following are present:AND any of the following are present: DepressionDepression HypertensionHypertension Gastro esophageal Reflux DiseaseGastro esophageal Reflux Disease DiabetesDiabetes Congestive Heart FailureCongestive Heart Failure ObesityObesity

DiagnosisDiagnosis

► Diagnosis is confirmed Diagnosis is confirmed with by with by polysomnography, polysomnography, measuring:measuring: AirflowAirflow Respiratory activityRespiratory activity Chin electromyographyChin electromyography ECGECG EEGEEG ElectrooculogramElectrooculogram Arterial oxygen Arterial oxygen

saturation during sleepsaturation during sleep

► At least 30 episodes At least 30 episodes over 7 hours of REM over 7 hours of REM and NREM sleep.and NREM sleep.

► OROR► At least 5 apneic At least 5 apneic

episodes per hour.episodes per hour.

Neuropsychological DeficitsNeuropsychological Deficits

►Sustained Attention and ConcentrationSustained Attention and Concentration

► Immediate and Delayed Recall of Immediate and Delayed Recall of Visual and Verbal InformationVisual and Verbal Information

►Executive FunctioningExecutive Functioning

►Processing SpeedProcessing Speed

Deficits (continued)Deficits (continued)

►Selective attention, mental flexibility, Selective attention, mental flexibility, impulse control, behavioral and impulse control, behavioral and emotional regulation, and emotional regulation, and metacognition in children (Beebe, metacognition in children (Beebe, 2004).2004).

►Deficits on visual memory, Deficits on visual memory, concentration, and auditory reaction concentration, and auditory reaction time (Laakso, Herrala, & Rikka (1999). time (Laakso, Herrala, & Rikka (1999).

Neuropsychological Deficits Neuropsychological Deficits (continued)(continued)

►Apperceptive AgnosiaApperceptive Agnosia

►Motor disturbances: posture, gait, Motor disturbances: posture, gait, involuntary movements, Parkinsonian involuntary movements, Parkinsonian symptoms, limb appraxia.symptoms, limb appraxia.

Psychological: Depression, personality Psychological: Depression, personality changes, and emotional lability.changes, and emotional lability.

Neuropsychological TestingNeuropsychological Testing

►May look similar to TBI or Carbon May look similar to TBI or Carbon Monoxide poisoning on testing: however, Monoxide poisoning on testing: however, less depression and more anxiety.less depression and more anxiety.

► Impairment on Stroop: Errors as well as Impairment on Stroop: Errors as well as RT (Van Diest, 2000).RT (Van Diest, 2000).

►Mean processing speed is 93 when Mean processing speed is 93 when compared to age matched sample (100). compared to age matched sample (100). Apnea index >30 mean processing speed Apnea index >30 mean processing speed is 87.4. (Cassel, 1989).is 87.4. (Cassel, 1989).

Testing (continued)Testing (continued)

►Bender Gestalt: Spatial Bender Gestalt: Spatial disorganization, poor visual disorganization, poor visual perception, distractability, irritability.perception, distractability, irritability.

►WMS: Short-term memory WMS: Short-term memory impairment, new learning impairment, impairment, new learning impairment, visual perceptual deficits.visual perceptual deficits.

►WAIS-R: Global ImpairmentWAIS-R: Global Impairment

(Kales, et al., 1985b).(Kales, et al., 1985b).

Testing (continued)Testing (continued)

►Deficits on: Trails B, PASAT, WMS Deficits on: Trails B, PASAT, WMS delays (Findley et al., 1986)delays (Findley et al., 1986)

►WMS visual Delay, Rey – O delay, WCS WMS visual Delay, Rey – O delay, WCS visual delay, WAIS PIQ associated with visual delay, WAIS PIQ associated with oxygen desaturations greater than 4% oxygen desaturations greater than 4% (Block et al., 1986).(Block et al., 1986).

►WMS Stories delay, Clock Drawing test WMS Stories delay, Clock Drawing test (Telakivi et al., 1988).(Telakivi et al., 1988).

Neuropsychological TestingNeuropsychological Testing

►MMPI: higher scores than matched MMPI: higher scores than matched controls on nearly all scales, controls on nearly all scales, predominantly reflecting depression predominantly reflecting depression and somatization (Kelly, et al. 1990).and somatization (Kelly, et al. 1990).

►Elevated SCLR-90Elevated SCLR-90

►Standard neuropsychological batteries Standard neuropsychological batteries not capable of correctly identifying not capable of correctly identifying apnea related deficits. (Telakivi, et al., apnea related deficits. (Telakivi, et al., 1993).1993).

Animal TestingAnimal Testing

►Aptopsis in cortex and CA1 region of Aptopsis in cortex and CA1 region of hippocampus.hippocampus.

►Spatial learning deficits in rats (Row, Spatial learning deficits in rats (Row, 2002).2002).

►Rats 10-25 days post-natal had Rats 10-25 days post-natal had significantly higher susceptibility to significantly higher susceptibility to hypoxia.hypoxia.

Mechanisms of ImpairmentMechanisms of Impairment

►Blood-Oxygen desaturations result in Blood-Oxygen desaturations result in neural tissue loss due to ischemia, neural tissue loss due to ischemia, acidosis, calcium influx, formation of acidosis, calcium influx, formation of oxygen radicals, and excitotoxicity.oxygen radicals, and excitotoxicity.

► Ischemia Induced neuronal loss: Ischemia Induced neuronal loss: Hypoxia alone may not cause neuronal Hypoxia alone may not cause neuronal

apoptosis. apoptosis. Hypoxia may increase neuronal p53, Hypoxia may increase neuronal p53,

which increases apoptosis processes.which increases apoptosis processes. Banasiak, 1998Banasiak, 1998

Mechanisms (continued)Mechanisms (continued)

►Sleep fragmentation interrupts REM Sleep fragmentation interrupts REM sleep; studies demonstrate REM sleep; studies demonstrate REM deprivation associated decrements of deprivation associated decrements of learning and memory.learning and memory.

►Comparison of Sleep Apnea Patients Comparison of Sleep Apnea Patients and patients with insomnia showed no and patients with insomnia showed no differences in neuropsychological differences in neuropsychological deficit. (Verstraeten, 1996)deficit. (Verstraeten, 1996)

►Desaturations greater than 4% cause Desaturations greater than 4% cause significantly more impairment (Telakivi significantly more impairment (Telakivi et al., 1988).et al., 1988).

Mechanisms (continued)Mechanisms (continued)

►Decreased hippocampal volume, resulting in Decreased hippocampal volume, resulting in memory impairment.memory impairment.

► Areas more vulnerable: neocortex, basal Areas more vulnerable: neocortex, basal ganglia, cerebellar Perkinje cells, primary ganglia, cerebellar Perkinje cells, primary visual cortex, frontal regions, and thalamus.visual cortex, frontal regions, and thalamus.

►Gray and white matter atrophyGray and white matter atrophy

► Ventricular EnlargementVentricular Enlargement

TreatmentTreatment►Continuous Positive Airway Pressure Continuous Positive Airway Pressure

(CPAP)(CPAP)

Bedard: study of patients before and Bedard: study of patients before and after 6 months of treatment:after 6 months of treatment: Improved daytime vigilance Improved daytime vigilance Some degree of sleepiness persistedSome degree of sleepiness persisted Most neuropsychological deficits Most neuropsychological deficits

normalized, with the exception of normalized, with the exception of planning abilities and manual dexterity.planning abilities and manual dexterity.

Effects of CPAPEffects of CPAP

After 6 months of CPAP treatment, After 6 months of CPAP treatment, improvement occurred on measures of:improvement occurred on measures of:

- Verbal Fluency- Verbal Fluency

-Cognitive Shifting-Cognitive Shifting

-Short Term Visual Memory and time -Short Term Visual Memory and time estimationestimation

(Caccappolo, 2000)(Caccappolo, 2000)

Some studies find no improvement in general Some studies find no improvement in general intellectual functioning (Gale, 2004).intellectual functioning (Gale, 2004).

Treatment (Continued)Treatment (Continued)►Mcardle, 1999: Predictors of long-term Mcardle, 1999: Predictors of long-term

(5 years) CPAP use are: (5 years) CPAP use are: snoring history snoring history apnea/hypopnea indexapnea/hypopnea index being malebeing male Lower ageLower age being a non-smokerbeing a non-smoker use within 1use within 1stst 3 months of treatment 3 months of treatment

correlated with use at 5 years: those correlated with use at 5 years: those using CPAP <2 hrs./night at 3 mo. not using CPAP <2 hrs./night at 3 mo. not likely to continuelikely to continue

Sleep Apnea in ChildrenSleep Apnea in Children

►1-3% have diagnosed sleep apnea1-3% have diagnosed sleep apnea►Up to 12 % may have primary snoringUp to 12 % may have primary snoring►Many infants and children also Many infants and children also

experience abnormal cardiac experience abnormal cardiac functioning during apneic episodes: functioning during apneic episodes: 52% brief sinus arrests, 28% with 52% brief sinus arrests, 28% with second degree atrioventricular block, second degree atrioventricular block, 16% with paroxysmal tachycardia16% with paroxysmal tachycardia

Effects of Apnea on ChildrenEffects of Apnea on Children

► Inattention/ Executive Functioning Deficits – Inattention/ Executive Functioning Deficits – symptoms mimicking/causing ADHDsymptoms mimicking/causing ADHD

► Minimal effects on measures of overall Minimal effects on measures of overall intelligence, verbal functioning, and intelligence, verbal functioning, and processing speed.processing speed.

► Mixed findings on memory impairment.Mixed findings on memory impairment.► Decreased academic performanceDecreased academic performance► OppositonalityOppositonality► Decreased emotional and behavioral Decreased emotional and behavioral

regulation.regulation.

Differential Diagnosis and Co-Differential Diagnosis and Co-morbid Disordersmorbid Disorders

►ADHD: 20-30% with Breathing related ADHD: 20-30% with Breathing related Sleep disorders may have clinically Sleep disorders may have clinically significant symptoms (Gozal, 1998).significant symptoms (Gozal, 1998).

►Learning Disabilities: among 13-14 Learning Disabilities: among 13-14 y.old’s, in the lower quartile of their y.old’s, in the lower quartile of their class, early childhood snoring was more class, early childhood snoring was more frequently reported (Gozal, 2001).frequently reported (Gozal, 2001).

(Differential Continued)(Differential Continued)

►Failure to ThriveFailure to Thrive►Emotional DisordersEmotional Disorders►Conduct DisordersConduct Disorders

Treatment of ChildrenTreatment of Children

►Unlikely to remit without treatmentUnlikely to remit without treatment►May intensify at a much faster rate May intensify at a much faster rate

than in adults.than in adults.►Tonsillectomy or Adenoidectomy often Tonsillectomy or Adenoidectomy often

used: studies have shown increase in used: studies have shown increase in mean grades during in second graders mean grades during in second graders (Gozal, 1998).(Gozal, 1998).

► Improvements may be only partial: Improvements may be only partial: short-term memory may not fully short-term memory may not fully recover (Gozal, 2001).recover (Gozal, 2001).