The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA
Nick A Antic, Peter Catcheside, Catherine Buchan, Michael Hensley, Matthew T Naughton, Sharn Rowland, Bernadette Williamson, Samantha Windler, R Doug McEvoy, Nick A Antic, Peter Catcheside, Catherine Buchan, Michael Hensley, Matthew T Naughton, Sharn Rowland, Bernadette Williamson, Samantha Windler, R Doug McEvoy
Abstract
Study objectives: The study aimed to document the neurobehavioral outcomes of patients referred to and treated by a sleep medicine service for moderate to severe obstructive sleep apnea (OSA). In particular, we aimed to establish the proportion of patients who, while appearing to have optimal continuous positive airway pressure (CPAP) adherence, did not normalize their daytime sleepiness or neurocognitive function after 3 months of CPAP therapy despite effective control of OSA.
Design: Multicenter clinical-effectiveness study.
Setting: Three academic sleep centers in Australia.
Participants: Patients referred to a sleep medicine service with moderate to severe OSA (n = 174).
Intervention: CPAP.
Measurements and results: Participants were assessed pretreatment and again after 3 months of CPAP therapy. At the beginning and at the conclusion of the trial, participants completed a day of testing that included measures of objective and subjective daytime sleepiness, neurocognitive function, and quality of life. In patients with symptomatic moderate to severe OSA (i.e., apnea-hypopnea index > 30/h), we found a treatment dose-response effect for CPAP in terms of Epworth Sleepiness Scale scores (P < 0.001). Several key indexes of neurobehavior (e.g., Functional Outcomes of Sleep Questionnaire, Epworth Sleepiness Scale) currently used to assess treatment response failed to normalize in a substantial group of patients after 3 months of CPAP treatment, even in those who were maximally compliant with treatment. Forty percent of patients in this trial had an abnormal Epworth Sleepiness Scale score at the conclusion of the trial. In addition, we showed no dose-response effect with the Maintenance of Wakefulness Test, raising doubts as to the clinical utility of the Maintenance of Wakefulness Test in assessing treatment response to CPAP in patients with OSA.
Conclusions: Our study suggests that a greater percentage of patients achieve normal functioning with longer nightly CPAP duration of use, but a substantial proportion of patients will not normalize neurobehavioral responses despite seemingly adequate CPAP use. It is thus crucial to adequately assess patients after CPAP therapy and seek alternate etiologies and treatments for any residual abnormalities.
Keywords: OSA; neurobehavioral function; neurocognitive function.
Figures
![Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3001789/bin/aasm.34.1.111a.jpg)
![Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3001789/bin/aasm.34.1.111b.jpg)
Figure 3
Total cumulative proportion of patients…
Figure 3
Total cumulative proportion of patients with abnormal baseline values achieving normal Epworth Sleepiness…
Figure 4
(A) Total executive maze errors…
Figure 4
(A) Total executive maze errors and (B) choice reaction time as a function…
- Identifying moderators of CPAP efficacy.Aloia MS. Aloia MS. Sleep. 2011 Jan 1;34(1):9-10. doi: 10.1093/sleep/34.1.9. Sleep. 2011. PMID: 21203378 Free PMC article. No abstract available.
- Effects of CPAP on daytime function.Montserrat JM, Rodenstein D, Barbé F. Montserrat JM, et al. Sleep. 2011 Jul 1;34(7):821; author reply 823, 825. doi: 10.5665/SLEEP.1090. Sleep. 2011. PMID: 21731123 Free PMC article. No abstract available.
- Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning.Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI. Weaver TE, et al. Sleep. 2007 Jun;30(6):711-9. doi: 10.1093/sleep/30.6.711. Sleep. 2007. PMID: 17580592 Free PMC article.
- Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: The Apnea Positive Pressure Long-term Efficacy Study (APPLES).Kushida CA, Nichols DA, Holmes TH, Quan SF, Walsh JK, Gottlieb DJ, Simon RD Jr, Guilleminault C, White DP, Goodwin JL, Schweitzer PK, Leary EB, Hyde PR, Hirshkowitz M, Green S, McEvoy LK, Chan C, Gevins A, Kay GG, Bloch DA, Crabtree T, Dement WC. Kushida CA, et al. Sleep. 2012 Dec 1;35(12):1593-602. doi: 10.5665/sleep.2226. Sleep. 2012. PMID: 23204602 Free PMC article. Clinical Trial.
- Continuous Positive Airway Pressure Improves Quality of Life in Women with Obstructive Sleep Apnea. A Randomized Controlled Trial.Campos-Rodriguez F, Queipo-Corona C, Carmona-Bernal C, Jurado-Gamez B, Cordero-Guevara J, Reyes-Nuñez N, Troncoso-Acevedo F, Abad-Fernandez A, Teran-Santos J, Caballero-Rodriguez J, Martin-Romero M, Encabo-Motiño A, Sacristan-Bou L, Navarro-Esteva J, Somoza-Gonzalez M, Masa JF, Sanchez-Quiroga MA, Jara-Chinarro B, Orosa-Bertol B, Martinez-Garcia MA; Spanish Sleep Network. Campos-Rodriguez F, et al. Am J Respir Crit Care Med. 2016 Nov 15;194(10):1286-1294. doi: 10.1164/rccm.201602-0265OC. Am J Respir Crit Care Med. 2016. PMID: 27181196 Clinical Trial.
- Mandibular advancement device vs. CPAP in the treatment of obstructive sleep apnea: are they equally effective in Short term health outcomes?White DP, Shafazand S. White DP, et al. J Clin Sleep Med. 2013 Sep 15;9(9):971-2. doi: 10.5664/jcsm.3008. J Clin Sleep Med. 2013. PMID: 23997711 Free PMC article.
- Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.Wozniak DR, Lasserson TJ, Smith I. Wozniak DR, et al. Cochrane Database Syst Rev. 2014 Jan 8;(1):CD007736. doi: 10.1002/14651858.CD007736.pub2. Cochrane Database Syst Rev. 2014. PMID: 24399660 Updated. Review.
- Continuous positive airway pressure improved daytime sleepiness and memory function in patients with obstructive sleep apnea.Hong YL, Shen YC, Chang ET, Kung SC. Hong YL, et al. Tzu Chi Med J. 2022 Aug 23;35(1):84-88. doi: 10.4103/tcmj.tcmj_4_22. eCollection 2023 Jan-Mar. Tzu Chi Med J. 2022. PMID: 36866346 Free PMC article.
- Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement.May AM, Patel SR, Yamauchi M, Verma TK, Weaver TE, Chai-Coetzer CL, Thornton JD, Ewart G, Showers T, Ayas NT, Parthasarathy S, Mehra R, Billings ME. May AM, et al. Am J Respir Crit Care Med. 2023 Feb 1;207(3):244-254. doi: 10.1164/rccm.202210-1846ST. Am J Respir Crit Care Med. 2023. PMID: 36722719 Free PMC article.
- Reliability and Efficacy of the Epworth Sleepiness Scale: Is There Still a Place for It?Scharf MT. Scharf MT. Nat Sci Sleep. 2022 Dec 13;14:2151-2156. doi: 10.2147/NSS.S340950. eCollection 2022. Nat Sci Sleep. 2022. PMID: 36536636 Free PMC article. Review.
- Association between Patient- and Partner-Reported Sleepiness Using the Epworth Sleepiness Scale in Patients with Obstructive Sleep Apnoea.Chaidas K, Lamprou K, Stradling JR, Nickol AH. Chaidas K, et al. Life (Basel). 2022 Sep 29;12(10):1523. doi: 10.3390/life12101523. Life (Basel). 2022. PMID: 36294958 Free PMC article.
- Retinal and Choroidal Effects of Continuous Positive Airway Pressure as Treatment for Sleep Apnea: Results at 12 Months.Naranjo-Bonilla P, Giménez-Gómez R, Muñoz-Villanueva MDC, Jurado-Gámez B. Naranjo-Bonilla P, et al. Int J Environ Res Public Health. 2022 Oct 3;19(19):12637. doi: 10.3390/ijerph191912637. Int J Environ Res Public Health. 2022. PMID: 36231937 Free PMC article.
- Multicenter Study
- Randomized Controlled Trial
- Research Support, Non-U.S. Gov't
- Cognition*
- Continuous Positive Airway Pressure*
- Female
- Humans
- Male
- Middle Aged
- Neuropsychological Tests
- Patient Compliance
- Quality of Life / psychology
- Sleep
- Sleep Apnea, Obstructive / psychology
- Sleep Apnea, Obstructive / therapy*
- Surveys and Questionnaires
- Treatment Outcome
- Wakefulness
- Full Text Sources
- Medical
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![Figure 3](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3001789/bin/aasm.34.1.111c.jpg)
Figure 4
(A) Total executive maze errors…
Figure 4
(A) Total executive maze errors and (B) choice reaction time as a function…
- Identifying moderators of CPAP efficacy.Aloia MS. Aloia MS. Sleep. 2011 Jan 1;34(1):9-10. doi: 10.1093/sleep/34.1.9. Sleep. 2011. PMID: 21203378 Free PMC article. No abstract available.
- Effects of CPAP on daytime function.Montserrat JM, Rodenstein D, Barbé F. Montserrat JM, et al. Sleep. 2011 Jul 1;34(7):821; author reply 823, 825. doi: 10.5665/SLEEP.1090. Sleep. 2011. PMID: 21731123 Free PMC article. No abstract available.
- Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning.Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI. Weaver TE, et al. Sleep. 2007 Jun;30(6):711-9. doi: 10.1093/sleep/30.6.711. Sleep. 2007. PMID: 17580592 Free PMC article.
- Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: The Apnea Positive Pressure Long-term Efficacy Study (APPLES).Kushida CA, Nichols DA, Holmes TH, Quan SF, Walsh JK, Gottlieb DJ, Simon RD Jr, Guilleminault C, White DP, Goodwin JL, Schweitzer PK, Leary EB, Hyde PR, Hirshkowitz M, Green S, McEvoy LK, Chan C, Gevins A, Kay GG, Bloch DA, Crabtree T, Dement WC. Kushida CA, et al. Sleep. 2012 Dec 1;35(12):1593-602. doi: 10.5665/sleep.2226. Sleep. 2012. PMID: 23204602 Free PMC article. Clinical Trial.
- Continuous Positive Airway Pressure Improves Quality of Life in Women with Obstructive Sleep Apnea. A Randomized Controlled Trial.Campos-Rodriguez F, Queipo-Corona C, Carmona-Bernal C, Jurado-Gamez B, Cordero-Guevara J, Reyes-Nuñez N, Troncoso-Acevedo F, Abad-Fernandez A, Teran-Santos J, Caballero-Rodriguez J, Martin-Romero M, Encabo-Motiño A, Sacristan-Bou L, Navarro-Esteva J, Somoza-Gonzalez M, Masa JF, Sanchez-Quiroga MA, Jara-Chinarro B, Orosa-Bertol B, Martinez-Garcia MA; Spanish Sleep Network. Campos-Rodriguez F, et al. Am J Respir Crit Care Med. 2016 Nov 15;194(10):1286-1294. doi: 10.1164/rccm.201602-0265OC. Am J Respir Crit Care Med. 2016. PMID: 27181196 Clinical Trial.
- Mandibular advancement device vs. CPAP in the treatment of obstructive sleep apnea: are they equally effective in Short term health outcomes?White DP, Shafazand S. White DP, et al. J Clin Sleep Med. 2013 Sep 15;9(9):971-2. doi: 10.5664/jcsm.3008. J Clin Sleep Med. 2013. PMID: 23997711 Free PMC article.
- Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.Wozniak DR, Lasserson TJ, Smith I. Wozniak DR, et al. Cochrane Database Syst Rev. 2014 Jan 8;(1):CD007736. doi: 10.1002/14651858.CD007736.pub2. Cochrane Database Syst Rev. 2014. PMID: 24399660 Updated. Review.
- Continuous positive airway pressure improved daytime sleepiness and memory function in patients with obstructive sleep apnea.Hong YL, Shen YC, Chang ET, Kung SC. Hong YL, et al. Tzu Chi Med J. 2022 Aug 23;35(1):84-88. doi: 10.4103/tcmj.tcmj_4_22. eCollection 2023 Jan-Mar. Tzu Chi Med J. 2022. PMID: 36866346 Free PMC article.
- Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement.May AM, Patel SR, Yamauchi M, Verma TK, Weaver TE, Chai-Coetzer CL, Thornton JD, Ewart G, Showers T, Ayas NT, Parthasarathy S, Mehra R, Billings ME. May AM, et al. Am J Respir Crit Care Med. 2023 Feb 1;207(3):244-254. doi: 10.1164/rccm.202210-1846ST. Am J Respir Crit Care Med. 2023. PMID: 36722719 Free PMC article.
- Reliability and Efficacy of the Epworth Sleepiness Scale: Is There Still a Place for It?Scharf MT. Scharf MT. Nat Sci Sleep. 2022 Dec 13;14:2151-2156. doi: 10.2147/NSS.S340950. eCollection 2022. Nat Sci Sleep. 2022. PMID: 36536636 Free PMC article. Review.
- Association between Patient- and Partner-Reported Sleepiness Using the Epworth Sleepiness Scale in Patients with Obstructive Sleep Apnoea.Chaidas K, Lamprou K, Stradling JR, Nickol AH. Chaidas K, et al. Life (Basel). 2022 Sep 29;12(10):1523. doi: 10.3390/life12101523. Life (Basel). 2022. PMID: 36294958 Free PMC article.
- Retinal and Choroidal Effects of Continuous Positive Airway Pressure as Treatment for Sleep Apnea: Results at 12 Months.Naranjo-Bonilla P, Giménez-Gómez R, Muñoz-Villanueva MDC, Jurado-Gámez B. Naranjo-Bonilla P, et al. Int J Environ Res Public Health. 2022 Oct 3;19(19):12637. doi: 10.3390/ijerph191912637. Int J Environ Res Public Health. 2022. PMID: 36231937 Free PMC article.
- Multicenter Study
- Randomized Controlled Trial
- Research Support, Non-U.S. Gov't
- Cognition*
- Continuous Positive Airway Pressure*
- Female
- Humans
- Male
- Middle Aged
- Neuropsychological Tests
- Patient Compliance
- Quality of Life / psychology
- Sleep
- Sleep Apnea, Obstructive / psychology
- Sleep Apnea, Obstructive / therapy*
- Surveys and Questionnaires
- Treatment Outcome
- Wakefulness
- Full Text Sources
- Medical
![Figure 4](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3001789/bin/aasm.34.1.111d.jpg)
Source: PubMed