ABSTRACT
The primary events of obstructed breathing during sleep, snoring and obstruction of
the upper airway, cause hypoxemia, sleep fragmentation, and daytime sleepiness. Obstructed
breathing during sleep can have negative effects on mental processes, behavior, and
interpersonal relations. This article reviews some of the cognitive, emotional, and
social aspects of obstructive sleep apnea in adults and children. Apnea is associated
with cognitive impairments but these are generally mild. Most studies suggest that
these impairments improve with CPAP but evidence suggests that some changes may be
permanent. Even mild apnea may worsen depression and quality of life. Apnea may have
more profound effects in children but the findings are inconclusive. This may be due
to difficulty in recognizing sleep apnea in children, the subtle nature of the disorder,
the lack of daytime sleepiness, and the imposition of adult norms on children's sleep
studies.
KEYWORDS
Cognitive functioning - psychosocial functioning - quality of life - ADHD
REFERENCES
- 1 Golden C J, Strider M A, Ariel R, Golden E. Neuropsychology and medical disorders. In:
Filskov, SB and Boll, TJ Handbook of Clinical Neuropsychology, Vol 2 New York; John
Wiley and Sons 1986: 257-278
- 2
Tune G S.
Psychological effects of hypoxia: review of certain literature from the period 1950-1963.
Percept Mot Skills.
1964;
19
551-562
- 3 Heath D, Williams D R. Man at High Altitude: The Pathophysiology of Acclimatization
and Adaptation. Edinburgh; Churchill, Livingstone 1981: 314-318
- 4
Berry D T, Webb W B, Block A J, Bauer R M, Switzer D A.
Nocturnal hypoxia and neuropsychological variables.
J Clin Exp Neuropsychol.
1986;
8
229-238
- 5
Grant I, Heaton R K, McSweeny A J, Adams K M, Timms R M.
Brain dysfunction in COPD.
Chest.
1980;
77
308-309
- 6
Huppert F.
Memory impairment associated with chronic hypoxia.
Thorax.
1982;
37
858-860
- 7
McSweeny A J, Heaton R K, Grant I, Cugell G, Solliday N, Timms R M.
Chronic obstructive pulmonary disease: socioemotional adjustment and life quality.
Chest.
1980;
77(2 Suppl)
309-311
- 8
Grant I, Heaton R K, McSweeny A J, Adams K M, Timms R M.
Neuropsychologic findings in hypoxemic chronic obstructive pulmonary disease.
Arch Intern Med.
1982;
142
1470-1476
- 9
Prigatano G P, Parsons O, Wright E, Levin D C, Hawryluk G.
Neuropsychological test performance in mildly hypoxemic patients with chronic obstructive
pulmonary disease.
J Consult Clin Psychol.
1983;
51
108-116
- 10
Jacobs E A, Winter P M, Alvis H J, Small S M.
Hyperoxygenation effect on cognitive functioning in the aged.
N Engl J Med.
1969;
281
753-757
- 11
Krop H D, Block A J, Cohen E.
Neuropsychologic effects of continuous oxygen therapy in chronic obstructive pulmonary
disease.
Chest.
1973;
64
317-322
- 12
Gulevich G, Dement W, Johnson L.
Psychiatric and EEG observations on a case of prolonged (264 hours) wakefulness.
Arch Gen Psychiatry.
1966;
15
29-35
- 13
Passnau R O, Naitoh P, Stien S et al..
The psychological effects of 205 hours of sleep deprivation.
Arch Gen Psychiatry.
1968;
18
496-505
- 14
Pilcher J J, Huffcutt A I.
Effects of sleep deprivation on performance: a meta-analysis.
Sleep.
1996;
19
318-326
- 15
Hartman E, Orzack M H, Branconnier R.
Deficits produced by sleep deprivation: reversal by d- and l-amphetamine.
Sleep Res.
1974;
3
151
- 16 Parkes J D. Sleep and Its Disorders. London; WB Saunders 1985 19
- 17
Horne J.
Sleep loss and “divergent” thinking ability.
Sleep.
1988;
11
528-536
- 18
Binks P G, Waters W F, Hurry M.
Short-term total sleep deprivations does not selectively impair higher cortical functioning.
Sleep.
1999;
22
328-334
- 19
Bonnet M H.
Effect of sleep disruption on sleep, performance and mood.
Sleep.
1985;
8
11-19
- 20
Bonnet M H.
Performance and sleepiness following moderate sleep disruption and slow wave sleep
deprivation.
Physiology and Behavior.
1986;
37
915-918
- 21
Bonnet M H.
Cognitive effects of sleep and sleep fragmentation.
Sleep.
1993;
16
S65-S67
- 22 Culebras A. Normal sleep. In: Lee-Chiong TL, Sateia MJ, Carskadon MA Sleep Medicine. Philadelphia;
Hanley and Belfus 2002 6
- 23 Riley T L, Ferber R. Behavioral aspects of sleep. In: Riley TL Clinical Aspects
of Sleep and Sleep Disturbance. Boston; Butterworth 1985: 39-60
- 24
Roth T, Costa e Silva J A, Chase M H.
Sleep and cognitive (memory) function: research and clinical perspectives.
Sleep Med.
2001;
2
379-387
- 25 Garcia-Rill E. Mechanisms of sleep and wakefulness. In: Lee-Chiong TL, Sateia MJ,
Carskadon MA Sleep Medicine Philadelphia; Hanley and Belfus 2002 36
- 26 Mendelson W B. Human Sleep: Research and Clinical Care. New York; Plenum 1987
- 27
Levine B, Roehrs T, Stepanski E, Zorick F, Roth T.
Fragmenting sleep diminishes its recuperative value.
Sleep.
1987;
10
590-599
- 28
Lavie P.
Nasal obstructions, sleep, and mental function.
Sleep.
1983;
6
244-246
- 29 Guilleminault C, van der Hoed J, Mitler M. Clinical overview of the sleep apnea
syndromes. In: Guilleminault C, Dement WC Sleep Apnea Syndromes New York; Alan R.
Liss 1978: 1-12
- 30
Watson R, Greenberg G, Deptula D.
Neuropsychological performance following treatment of sleep apnea.
Sleep Res.
1984;
14
136
- 31
Kales A, Caldwell A, Cadieux R, Vela-Bueno A, Ruch L, Mayes S.
Severe obstructive sleep apnea, II: Associated psychopathology and psychosocial consequences.
J Chronic Dis.
1985;
38
427-434
- 32
Findley L J, Barth J T, Powers D C et al..
Cognitive impairment in patients with obstructive sleep apnea and associated hypoxemia.
Chest.
1986;
90
686-690
- 33
Greenberg G D, Watson R K, Deptula D.
Neuropsychological dysfunction in sleep apnea.
Sleep.
1987;
10
254-262
- 34
Nichols C D, Kapen S, Greiffenstein M F.
Determinants of neuropsychological deficits in obstructive sleep apnea.
J Sleep Res.
1988;
17
227
- 35
Montplaisir J, Bedard M A, Richer F, Rouleau I.
Neurobehavioral manifestations in obstructive sleep apnea syndrome before and after
treatment with continuous positive airway pressure.
Sleep.
1992;
15(suppl 6)
S17-S19
- 36
Adams N, Strauss M, Schluchter M, Redline S.
Relation of measures of sleep-disordered breathing to neuropsychological functioning.
Am J Respir Crit Care Med.
2001;
163
1626-1631
- 37
Beebe D W, Groesz L, Wells C, Nichols A, McGee K.
The neuropsychological effects of obstructive sleep apnea: a meta-analysis of norm-referenced
and case controlled data.
Sleep.
2003;
26
298-307
- 38
Sateia M J.
Neuropsychological impairment and quality of life in obstructive sleep apnea.
Clin Chest Med.
2003;
24
249-259
- 39
Cheshire K, Engelman H, Deary I, Shapiro C, Douglas N J.
Factors impairing daytime performance in patients with sleep apnea/hypopnea sybdrome.
Arch Intern Med.
1992;
152
538-541
- 40
Bedard M A, Montplaisir J, Richer F, Malo J, Rouleau I.
Persistent neuropsychological deficits and vigilance impairments in sleep apnea syndrome
after treatment with continuous positive airway pressure.
J Clin Exp Neuropsychol.
1993;
15
330-341
- 41
Ferini-Strambi L, Baietto C, Di Gioia M R et al..
Cognitive dysfunction in patients with obstructive sleep apnea (OSA): partial reversibility
after continuous positive airway pressure (CPAP).
Brain Res Bull.
2003;
61
87-92
- 42
Boland L L, Shahar E, Iber C, Knopman D S, Kuo T F, Nieto F J.
Measures of cognitive function in persons with varying degrees of sleep-disordered
breathing: the Sleep Heart Health Study.
J Sleep Res.
2002;
11
265-272
- 43
Lojander J, Kajaste S, Maasilta P, Partinen M.
Cognitive function and treatment of obstructive sleep apnea syndrome.
J Sleep Res.
1999;
8
71-76
- 44
Telekavi T, Kajaste S, Partinen M, Koskenvuo M, Salmi T, Kaprio J.
Cognitive function in middle-aged snorers and controls: role of excessive daytime
somnolence and sleep related hypoxic events.
Sleep.
1988;
11
454-462
- 45
Telekavi T, Kajaste S, Partinen M, Brander P, Nyhlom A.
Cognitive function in obstructive sleep apnea.
Sleep.
1993;
16
S74-S75
- 46
Block A J, Berry D, Webb W.
Nocturnal hypoxemia and neuropsychological deficits in men who snore.
Eur J Resp Dis Suppl.
1986;
146
405-408
- 47
Valencia-Flores M, Bliwise D L, Guilleminault C, Cilveti R, Clerk A.
Cognitive function in patients with sleep apnea after acute nocturnal nasal continuous
positive airway pressure (CPAP) treatment: sleepiness and hypoxemia effects.
J Clin Exp Neuropsychol.
1996;
18
197-210
- 48
Gall R, Isaac L, Kryger M.
Quality of life in mild obstructive sleep apnea.
Sleep.
1993;
16
S59-S61
- 49
Kim H C, Young T, Matthews C G, Weber S M, Woodard A R, Palta M.
Sleep disordered breathing and neuropsychological deficits.
Am J Respir Crit Care Med.
1997;
156
1813-1819
- 50
Klonoff H, Fleetham J, Taylor R, Clark C.
Treatment outcome of obstructive sleep apnea: Physiological and neuropsychological
concomitants.
J Nerv Ment Dis.
1987;
175
208-212
- 51
Aikens J E, Mendelson W B.
A matched comparison of MMPI responses in patients with primary snoring or obstructive
sleep apnea.
Sleep.
1999;
22
355-359
- 52
Aikens J E, Caruana-Montaldo B, Vanable P A, Tadimeti L, Mendelson W B.
MMPI correlates of sleep and respiratory disturbance in obstructive sleep apnea.
Sleep.
1999;
22
362-369
- 53 Watson R, Greenberg G, Bakos L. Sleep apnea and depression. Sleep Res 1987 16:
293
- 54
Ramos Platon M J, Espinar Sierra J.
Changes in psychopathlogical symptoms in sleep apnea patients after treatment with
nasal continuous positive airway pressure.
Int J Neurosci.
1992;
62
173-195
- 55
Reynolds C F, Kupfer D J, McEachran A B, Taska L S, Sewitch D E, Coble P A.
Depressive psychopathology in male sleep apneics.
J Clin Psychiatry.
1984;
45
287-290
- 56
Reynolds C F, Coble P A, Spiker P G, Neil J F, Holzer B C, Kupfer D J.
Prevalence of sleep apnea and nocturnal myoclonus in major affective disorders: clinical
and polysomnographic findings.
J Nerv Ment Dis.
1982;
170
565-567
- 57
Gierz M, DuPont R, Morehouse R, Irwin M, Gillin J C.
Oxygen saturation during sleep in a psychiatric population.
Sleep Res.
1988;
17
180
- 58
Vandeputte M, de Weerd A.
Sleep disorders and depressive feelings: a global survey with the Beck depression
scale.
Sleep Med.
2003;
4
343-345
- 59
Pillar G, Lavie P.
Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance
index.
Chest.
1998;
114
697-703
- 60
Weaver T E.
Outcome measurement in sleep medicine practice and research, I: Assessment of symptoms,
subjective and objective daytime sleepiness, health-related quality of life and functional
status.
Sleep Med Rev.
2001;
5
103-128
- 61
Weaver T E.
Outcome measurement in sleep medicine practice and research, II: Assessment of neurobehavioral
performance and mood.
Sleep Med Rev.
2001;
5
223-236
- 62
Yu B H, Ancoli-Israel S, Dimsdale J E.
Effect of CPAP treatment on mood states in patients with sleep apnea.
J Psychiatr Res.
1999;
33
427-432
- 63
Borak J, Cieslicki J K, Koziej M, Matuszewski A, Zielinski J.
Effects of CPAP treatment on psychological status in patients with severe obstructive
sleep apnea.
J Sleep Res.
1996;
5
123-127
- 64
Cartwright R D, Knight S.
Silent partners: the wives of sleep apnea patients.
Sleep.
1987;
10
244-248
- 65
Veale D, Poussin G, Benes F, Pepin J L, Levy P.
Identification of quality of life concerns with obstructive sleep apnoea at the time
of initiation of continuous positive airway pressure: a discourse analysis.
Qual Life Res.
2002;
11
389-399
- 66
Bergner M, Bobbit R, Carter W B, Gilson B S.
The sickness impact profile: development and final revision of a health status measure.
Med Care.
1981;
19
787-805
- 67 Ware J, Snow K, Kosinski M et al.. SF-36 Health Survey. Manual and Interpreatation
Guide. Boston; The Health Institute, New England Medical Center 1990
- 68
D'Ambrosio C, Bowman T, Mohsenin V.
Quality of life in patients with obstructive sleep apnea: effect of nasal continuous
positive airway pressure: a prospective study.
Chest.
1999;
115
123-129
- 69
Fornas C, Ballester E, Arteta E et al..
Measurement of general health status in obstructive sleep apnea hypopnnea patients.
Sleep.
1995;
18
876-879
- 70
Weaver T, Maislin G, Chugh D et al..
Change in OSA symptoms after three months of CPAP use: a multisite study.
Sleep.
1998;
21(suppl)
250
- 71
Jenkinson C, Stradling J, Peterson S.
Comparison of three measures of three measures of quality of life outcome in the evaluation
of continuous positive airway pressure for sleep apnoea.
J Sleep Res.
1997;
6
199-204
- 72
Akashiba T, Kawahara S, Akahoshi T et al..
Relationship between quality of life and mood or depression in patients with severe
sleep apnea syndrome.
Chest.
2002;
122
861-865
- 73
Baldwin C N, Griffith K A, Nieto J, O'Connor G T, Walsleben J A, Redline S.
The association of sleep-disordered breathing and sleep symptoms with quality of life
in the sleep heart health study.
Sleep.
2001;
24
96-105
- 74 Guilleminault C. Clinical features and evaluation of obstructive sleep apnea. In:
Kryger MN, Roth T, Dement WC Principles and Practice of Sleep Medicine. 2nd. Philadelphia;
WB Saunders 1994: 667-677
- 75
Schmidt H S, Wise H A.
Significance of impaired penile tumescence and associated polysomnographic abnormalities
in the impotent patient.
J Urol.
1981;
126
348-351
- 76
Pressman M R, Diphilippo M A, Kendrick J I et al..
Problems in the interpretation of nocturnal penile tumescence studies: disruption
of sleep by occult sleep disorders.
J Urol.
1985;
136
595-598
- 77
Fanfulla F, Malaguti S, Montagna T et al..
Erectile dysfunction in men with obstructive sleep apnea: an early sign of nerve involvement.
Sleep.
2000;
23
775-781
- 78
Hirshkowitz M, Karacan I, Gurakar A, Williams R L.
Hypertension, erectile dysfunction and occult sleep apnea.
Sleep.
1989;
12
223-232
- 79
Santamaria J D, Prior J C, Fleetham J A.
Reversible reproductive dysfunction in men with obstructive sleep apnea.
Clin Endocrinol (Oxf).
1988;
28
461-470
- 80
Seftel A D, Strohl K P, Loye T L, Bayard D, Kress J, Netzer N C.
Erectile dysfunction and symptoms of sleep disorders.
Sleep.
2002;
25
643-647
- 81
Smith R, Ronald J, Delaive K, Walld R, Manfreda J, Kryger M.
What are obstructive sleep apnea patient's being treated for prior to this diagnosis?.
Chest.
2002;
121
164-172
- 82
Grunstein R R, Stenlof K, Hedner J A, Sjostrom L.
Impact of self-reported sleep-breathing disturbances on psychosocial performance in
the Swedish obese subjects (SOS) study.
Sleep.
1995;
18
635-643
- 83
Young T, Blustein J, Finn L, Palta M.
Sleep-disordered breathing and motor vehicle accidents in a population-based sample
of employed adults.
Sleep.
1997;
20
608-613
- 84 Carroll J L. Sleep-disordered breathing in children. In: Lee-Chiong T, Sateia MJ,
Carskadon M Sleep Medicine. Philadelphia; Hanley and Belfus 2002 265
- 85
Ali N J, Pitson D J, Stradling J R.
Snoring, sleep disturbance, and behavior in 4-5 year-olds.
Arch Dis Child.
1993;
68
360-366
- 86
Ali N J, Pitson D, Stradling J R.
Natural history of snoring and related behavior problems between the ages of 4 and
7 years.
Arch Dis Child.
1994;
71
74-76
- 87
Gislason T, Benediktsdottir B.
Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years
old: an epidemiologic study of lower limit of prevalence.
Chest.
1995;
107
963-966
- 88
Owen G O, Canter R J, Robinson A.
Snoring, apnoea and ENT symptoms in a paediatric community.
Clin Otolaryngol.
1996;
21
130-134
- 89
Blunden S, Lushington K, Kennedy D.
Cognitive and behavioural performance in children with sleep-related obstructive breathing
disorders.
Sleep Med Rev.
2001;
5
447-461
- 90
Carroll J L.
Obstructive sleep-disordered breathing in children: new controversies, new directions.
Clin Chest Med.
2003;
24
261-282
- 91
Gaultier C.
Clinical and therapeutic aspects of obstructive sleep apnea syndrome in infants and
children.
Sleep.
1992;
15
S36-S38
- 92
Goodwin J L, Kaemingk K L, Fregosi R F et al..
Clinical outcomes associated with sleep disordered breathing in Caucasian and Hispanic
children: the Tucson children's assessment of sleep apnea study (TuCASA).
Sleep.
2003;
26
587-591
- 93
Marcus C, Omlin K, Basinki D et al..
Normal polysomnographic values for children and adolescents.
American Review of Respiratory Disease.
1992;
146
1235-1239
- 94
Brouilette R T, Fernbach S K</, Hunt C E.
Obstructive sleep apnea in infants and children.
J Pediatr.
1982;
100
31-40
- 95
Stradling J R, Thomas G, Warley A R.
Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms
in snoring children.
Lancet.
1990;
335
249-253
- 96
Gozal D.
Sleep-disordered breathing and school performance in children.
Pediatrics.
1998;
102(3 pt 1)
616-620
- 97
Weissbluth M, Davis A T, Poncher J, Reiff J.
Signs of airway obstruction during sleep and behavioral, developmental, and academic
problems.
J Dev Behav Pediatr.
1983;
4
119-121
- 98
Blunden S L, Lushington K, Kennedy D, Martin J, Dawson D.
Behaviour and neurocognitive function in children aged 5-10 years who snore compared
to controls.
J Clin Exp Neuropsychol.
2000;
22
554-568
- 99
Ali N J, Pitsn D, Stradling J R.
Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological
functioning.
Eur J Pediatr.
1996;
155
56-62
- 100
Owens J, Spirito A, Marcotte A, McGuinn M, Berkelhammer L.
Neuropsychological and behavioral correlates of obstructive sleep apnea syndrome in
children: A preliminary study.
Sleep Breath.
2000;
4
67-78
- 101
Rhodes S K, Shimoda K C, Waid L R et al..
Neurocognitive deficits in morbidly obese children with obstructive sleep apnea.
J Pediatr.
1995;
127
741-744
- 102
Guilleminault C, Pelayo R, Leger D, Clerk A, Bocian R CZ.
Recognition of sleep disordered breathing in children.
Pediatrics.
1996;
98
871-882
- 103
Gozal D, Pope D W.
Snoring during early childhood and academic performance at ages thirteen to fourteen
years.
Pediatrics.
2001;
107
1394-1399
- 104
Guilleminault C, Winkle R, Korobkin R, Simmons B.
Children and nocturnal snoring: evaluation of the effects of sleep related respiratory
resistive load and daytime functioning.
Eur J Pediatr.
1982;
139
165-171
- 105
O'Brien L M, Holbrook C R, Mervis C B et al..
Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally
reported symptoms of attention deficit/hyperactivity disorder.
Pediatrics.
2003;
111
554-563
- 106
Chervin R D, Dillon J E, Bassetti C, Ganoczy D A, Pituch K J.
Symptoms of sleep disorders: inattention and hyperactivity in children.
Sleep.
1997;
20
1185-1192
- 107
Goldstein N A, Fatima M, Campbell T F, Rosenfeld R M.
Child behavior and quality of life before and after tonsillectomy and adenoidectomy.
Arch Otolaryngol Head Neck Surg.
2002;
128
770-775
- 108
Carroll J L, McColley S A, Marcus C L, Curtis S, Loughlin G M.
Inability of clinical history to distinguish primary snoring from obstructive sleep
apnea syndrome in children.
Chest.
1995;
108
610-618
- 109
Rosen C, D'Andrea L, Haddad C.
Adult criteria for obstructive sleep apnea do not identify children with serious obstruction.
American Review of Respiratory Disease.
1992;
146
1231-1234
- 110 Landgraf J, Abetz L, Ware J. The CHQ User's Manual. 2nd. Boston; HealthAct 1999
- 111
Rosen C L, Palmero T M, Larkin E K, Redline S.
Health-related quality of life and sleep-disordered breathing in children.
Sleep.
2002;
25
657-666
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