The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA

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.

Figure 1

Continuous positive airway pressure (CPAP) adherence in Model A (nurse led) and Model B (physician led) care (A) and in the whole group (B). Values are percentage of patients in each category of mean CPAP compliance (hours per night).

Figure 2

(A) Pretreatment and posttreatment Epworth Sleepiness Scale (ESS) scores, (B) posttreatment maintenance of wakefulness test (MWT, min) mean sleep latency, and pretreatment and posttreatment (C) total Functional Outcomes of Sleep Questionnaire (FOSQ) and (D) SF-36 vitality scores as a function of continuous positive airway pressure (CPAP) compliance category. Values are mean ± SEM. The unbroken ESS horizontal line indicates the cutoff of 10 usually used to distinguish normal from abnormal results. The unbroken MWT horizontal line corresponds to the mean sleep latency cutoff value used to distinguish normal from abnormal results. *Indicates P < 0.05 pretreatment vs posttreatment. A, C, D: Total n = 174 (≤ 2 n = 46; > 2, < 4 n = 21; ≥ 4, < 5 n = 12; ≥ 5, < 6 n = 26, ≥ 6, < 7 n = 39; ≥ 7 n = 30), C Total n = 123 (≤ 2 n = 23; > 2, < 4 n = 14; ≥ 4, < 5 n = 10; ≥ 5, < 6 n = 21, ≥ 6, < 7 n = 30; ≥ 7 n = 25).

Figure 3

Total cumulative proportion of patients with abnormal baseline values achieving normal Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) values with increasing compliance derived from data within each compliance category shown in Table 2. Values are the percentage of patients returning to normal ESS and FOSQ scores with a given level of continuous positive airway pressure (CPAP) compliance. Total n = 174 (≤ 2 n = 46; > 2, < 4 n = 21; ≥ 4, < 5 n = 12; ≥ 5, < 6 n = 26, ≥ 6, < 7 n = 39; ≥ 7 n = 30).

Figure 4

(A) Total executive maze errors and (B) choice reaction time as a function of adherence category before and after treatment with continuous positive airway pressure (CPAP). Values are mean ± SEM. One hundred thirteen control subjects; 143 subjects with obstructive sleep apnea (≤ 2 n = 36; > 2, < 4 n = 17; ≥ 4, < 5 n = 8; ≥ 5, < 6 n = 20, ≥ 6, < 7 n = 32; ≥ 7 n = 30).