Helen Gotsopoulos

Neurobehavioral functioning in obstructive sleep apnea: differential effects of sleep quality, hypoxemia and subjective sleepiness

This study evaluated the relationship between neuropsychological and affective functioning, subjective sleepiness and sleep-disordered breathing in 100 patients with obstructive sleep apnea (OSA). Using principal components analysis, three indices of sleep-disordered breathing were identified from polysomnography: sleep disturbance, extent of nocturnal hypoxemia, and sleep quality. Poorer sleep quality was related to slower processing speed, somatic symptomatology and tension-anxiety levels. Nocturnal hypoxemia was related to visuconstructional abilities, processing speed and mental flexibility. Patients who had high levels of subjective sleepiness had poorer performances on a complex task of executive functioning and higher levels of tension-anxiety. These results imply a differential effect of sleep-disordered breathing on domains of neuropsychological functioning. Additionally, they suggest that a patient’s subjective level of sleepiness is a good predictor of certain aspects of neurobehavioral functioning.

Oral Appliance Therapy for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive, complete or partial closure of the upper airway during sleep, resulting in sleep fragmentation and oxygen desaturation. The disorder causes significant morbidity, particularly in terms of impairment of daytime functioning and the impact this has on quality of life. There is also evidence that links OSA to long-term cardiovascular morbidity, including hypertension, myocardial infarction, and stroke, and increased risk of motor vehicle accidents. There is clear evidence that effective treatment of OSA provides major benefit to patients.Nasal continuous positive airway pressure (CPAP) is the current treatment of choice, but its cumbersome nature makes tolerance and compliance less than optimal. This gives rise to the need for other alternatives that are equally effective, but more tolerable. There is growing interest in the use of oral appliances to treat snoring and OSA. The rationale is that advancement of the mandible and tongue impacts positively on upper airway caliber and function. There are many such types of appliances, and they have potential advantages over CPAP in that they are unobtrusive, make no noise, do not need a power source, and are potentially less costly.There is a growing evidence base to support the use of oral appliances in the management of OSA. Recent evidence from randomized controlled trials indicates that oral appliance therapy is effective in controlling OSA in up to 50% of patients, including some patients with more severe forms of OSA. This is associated with a significant improvement in symptoms, including snoring and daytime sleepiness. This evidence is strong for short term, and emerging for long-term treatment of OSA with oral appliances. Whilst direct comparisons with CPAP indicate the superiority of CPAP overall, similar outcomes between the two treatments appear to be achieved in a substantial subgroup of patients. Patient acceptance has, in general, been in favor of oral appliances.Notwithstanding the expanding role of oral appliance therapy, there are a number of limitations that are yet to be overcome. Key issues include the inability to reliably predict treatment outcome, the apparent need for an acclimatization period to attain maximal efficacy of treatment, uncertainty about selection of the appropriate ‘dosage’ of mandibular advancement required to control OSA in the individual patient, uncertainty about the influence of appliance design on treatment outcome and adverse effects, adherence to treatment, and potential long-term complications of therapy. These issues require resolution before oral appliance therapy can surpass CPAP as first-line treatment for OSA.