Review ArticleObstructive sleep apnea, depression and cognitive impairment
Introduction
Obstructive sleep apnea (OSA) has been classified as a sleep breathing disorder which contributes to oxidative stress. OSA occurs in at least 10% of the population, and leads to higher morbidity and mortality; nevertheless, associations between OSA severity and psychological or psychiatric problems remain unclear. OSA is characterized by repeated cessation or significant restrictions of airflow (apnea and hypopnea) present in sleep accompanied by oxygen desaturation and arousals [1]. Currently, it is the most common sleep disorder of breathing [1,2]. Craniofacial disharmony is a central risk aspect for the OSA [3]. The fatty accumulation in the pharynx may have a role in some very obese individuals [3]. The most OSA is linked to a narrow high-arched hard palate and mid-face hypoplasia with retro-positioning of the maxilla and chin (bringing the soft palate and tongue closer to the back of the throat [4]). The structural disproportions among the skeletal craniofacial and soft tissue structures disturb pharyngeal airway morphology in OSA patients. The proportions of the nasopharynx, pharyngeal length, and the cross-sectional area at the hard palate level, were linked with the severity of OSA [5].
Although (hetero) anamnestic information may be collected to determine the diagnosis of OSA, apnea hypopnea index (AHI) polysomnography (PSG) is a gold standard for proper diagnosis. AHI refers to the number of apnea or hypopnea episodes recorded per hour of sleep. An AHI of 5–14 indicates mild, 15–30 moderate and ≥30 severe OSA. Hypopnea and apnea interrupt deep sleep and rapid eye movements (REM) phase and cause sleep pattern fragmentation [6]. After awakening, patients do not feel relaxed and remain tired during the day. Night time symptoms include snoring, breathing breaks, feeling sick, excessive salivation, excessive sweating, gastroesophageal reflux, urination during the night, dry mouth and headache [7,8]. Day time symptoms include excessive sleepiness, loss of energy, irritability [9], withdrawal from social activities, difficulty in concentrating [10], cognitive dysfunction [11,12], anxiety or depressive mood problems [13], and psychomotor changes [9,14]. These symptoms show a marked similarity to the symptoms of major depressive disorder [15,16]. Up to 63% of patients with OSA have depressive symptoms [13,16,17]. Therefore, many sleep laboratories regularly evaluate the depressive symptoms of their patients using screening questionnaires [8]. The similarity in the phenotypic expression of OSA and depressive disorders may lead to misdiagnosing sleep apnea for depressive disorder and misuse of antidepressant therapy [18,19]. Diagnostics is performed in sleep laboratories. The most effective treatment is considered to be positive airway pressure (PAP) treatment – the most common mode of therapy is continuous positive airway pressure (CPAP) derived via different types of masks [[20], [21], [22]]. Surgical treatment might be efficient in some cases, especially in mild to moderate OSA in non-obese patients [5].
The prevalence of OSA in adults (39–59 years) is estimated to be between 2% and 14%, but in individuals with age over 60 years it is as high as 20% [2,23,24]. A critical epidemiological analysis of limited home polysomnography in the United States showed that the prevalence of OSA, defined by AHI > 15, was approximately 18% in the general population [25]. OSA significantly reduces the quality of life (QoL) [22,24]. It is also a risk factor for other health problems such as increased prevalence of cardiovascular diseases, hypertension, sudden death, and psychiatric conditions like depression, irritability, memory and cognitive impairment [[24], [25], [26], [27], [28]]. Many studies have confirmed that obesity, age, sex, snoring, pharyngeal anatomy abnormalities, and cephalometric characteristics may be risk factors for OSA [5,29,30].
In the literature, OSA is discussed as possible comorbidity of affective and cognitive disorders [[31], [32], [33]]. When unrecognized, OSA may worsen the symptoms of psychiatric disorders and prevent achieving of remission [32]. OSA is often considered and diagnosed late, even when snoring and apneas are noticed by medical staff. Studies combining untreated OSA with range of psychiatric disorders have emerged [34,35]. Recently, several studies connected untreated obstructive sleep apnea with a range of psychiatric disorders [[36], [37], [38], [39]]. This confirms that comorbid OSA may worsen symptoms of affective disorders. OSA shares many symptoms with depression (concentration disturbances, energy loss, and increased fatigue) and leads to the deepening of depressive symptomatology and the development of cognitive deficits [32,[38], [39], [40], [41]]. Untreated comorbid OSA leads to poor adherence to drug therapy, and in contrary, treatment of OSA improves the symptoms of depression [40,[42], [43], [44]].
Due to the contraindication of hypnotics and benzodiazepines in OSA, initial depressive treatment periods with polypharmacy may lead to a rapid worsening of OSA symptoms [45]. However, this contraindication can be minimized by using CPAP therapy during the period of sleep in severe depressive disorders.
The aim of the narrative review is to examine: (1) the relationship between OSAS and depressive and cognitive symptoms, and (2) the effect of OSAS treatment on psychiatric symptoms.
Section snippets
Method
Articles were acquired via PubMed and Web of Science published in the years between January 1990 and August 2018 were extracted. This article is narrative review, which describes and discusses the state of the knowledge of a topic of the OSA relation to psychiatric and cognitive problems from the contextual point of view. It consists of the critical examination of the literature published in PubMed, and Web of Science. Authors made a series of literature searches using the following keywords or
Depression in patients with OSA
Psychiatric comorbidities, especially depressive symptoms or depressive disorders, are often described in OSA patients [26,47]. Concerning emotional well-being, the disturbed sleep pattern negatively affects the stress system and thus increases the susceptibility of OSA individuals to depression [[47], [48], [49]]. The study of Kang et al. [50], revealed damages at insular cortex with correlation to symptoms of depression and anxiety (Hamilton depression scale and Hamilton anxiety scale) in OSA
Discussion
Our review article points out that patients with OSA can also suffer from additional problems, particularly higher depression and anxiety scores and diminished cognitive functions. It is essential to differentiate whether the depression score is connected to the OSA itself, or whether it rather is a manifestation of a comorbid depression disorder. Numerous findings concerning the psychiatric problems in OSA patients have been reported, however, their importance needs to be explored further, as
Conclusion
OSA is a severe illness that has a high prevalence in the adult population and will most likely continue to increase in the future due to the trend of increasing the average weight. In our conditions, sleep apnea is usually diagnosed too late, and despite repeated observations of typical night-time symptoms in inpatient care, clinicians rarely consider it. Untreated OSA worsens many cardiovascular diseases, prevents their compensation, impacts affective disorders, and often leads to worsening
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