New evidence indicates that obstructive sleep apnea can cause cognitive impairments in middle-aged men, regardless of whether they have other health issues or are overweight.
Obstructive sleep apnea (OSA) is a potentially dangerous health condition. It occurs when, during sleep, the throat muscles of afflicted individuals become lax and obstruct the flow of air to the lungs, causing them to frequently stop breathing. Common indicators of OSA encompass disturbed sleep, pronounced snoring, daytime lethargy, and persistent morning headaches – which can profoundly impair the lives of sufferers and their partners.
Currently, OSA is underdiagnosed, with estimates suggesting it may affect as much as 15 to 30% of men and 10 to 15% of women, equating to roughly 1 billion adults globally. Strikingly, an estimated 80% of these individuals are likely unaware they have the condition. Key risk factors associated with OSA include advancing age, obesity, tobacco use, persistent nasal congestion, hypertension, and being male.
Now, researchers from the UK, Germany, and Australia have shown for the first time that in middle-aged men, OSA can also cause early cognitive decline, even in patients who are otherwise healthy and not obese. The results were recently published in the journal Frontiers in Sleep.
“We show poorer executive functioning and visuospatial memory and deficits in vigilance, sustained attention, and psychomotor and impulse control in men with OSA. Most of these deficits had previously been ascribed to co-morbidities,” said Dr. Ivana Rosenzweig, a neuropsychiatrist who heads the Sleep and Brain Plasticity Centre at King’s College London, and the study’s lead author.
“We also demonstrated for the first time that OSA can cause significant deficits in social cognition.”
Rare cohort without co-morbidities
Rosenzweig and colleagues studied a group of 27 men between the ages of 35 and 70 with a new diagnosis of mild to severe OSA but without any co-morbidities. Such patients are relatively rare because most men and women with OSA have co-morbidities such as cardiovascular and metabolic disease, stroke, diabetes, chronic systemic inflammation, or depression.
The men were not currently smokers or alcohol abusers and were not obese (ie, with a body mass index (BMI) below 30). As a control, the researchers studied a group of seven age-, BMI-, and education-matched men without OSA. The OSA diagnosis was confirmed by a so-called WatchPAT test of their respiratory function during sleep at home, and also by video-polysomnography at King’s College sleep center. With the latter method, the brain waves of sleeping subjects were measured by electroencephalography (EEG), while their blood oxygen levels, heart rate, breathing, and eye and leg movements were tracked.
The scientists also tested the subjects’ cognitive function with the CANTAB or ‘Cambridge Neuropsychological Test Automated Battery’ of tests.
Premature cognitive decline
The results showed that patients with severe OSA had poorer vigilance, executive functioning, short-term visual recognition memory, and social and emotional recognition than the matched controls. Patients with mild OSA performed better in these domains than patients with severe OSA, but worse than the controls.
“The most significant deficits…were demonstrated in the tests that assess both simultaneous visual matching ability and short-term visual recognition memory for non-verbalizable patterns, tests of executive functioning and cued attentional set-shifting, in vigilance and psychomotor functioning, and lastly, in social cognition and emotion recognition,” wrote the authors.
The authors conclude that OSA is sufficient to cause these cognitive deficits, which previous studies had attributed to the most common co-morbidities of OSA such as systemic hypertension, cardiovascular and metabolic diseases, and type 2 diabetes.
But what is the mechanism by which OSA causes premature cognitive decline? The authors speculated that the cognitive deficits are due to intermittent low oxygen and high carbon dioxide in the blood, changes in blood flow to the brain, sleep fragmentation, and neuroinflammation in OSA patients.
“This complex interplay is still poorly understood, but it’s likely that these lead to widespread neuroanatomical and structural changes in the brain and associated functional cognitive and emotional deficits,” said Rosenzweig.
Whether co-morbidities have similar negative effects on cognition above and beyond those caused directly by OSA is not yet clear.
“Our study is a proof of concept. However, our findings suggest that co-morbidities likely worsen and perpetuate any cognitive deficits caused directly by OSA itself,” said Rosenzweig.
“What remains to be clarified in future studies is whether co-morbidities have an additive or synergistic effect on the latter deficits and whether there is a difference in brain circuitry in OSA patients with or without co-morbidities.”
Reference: “Distinct cognitive changes in male patients with obstructive sleep apnoea without co-morbidities” by Valentina Gnoni, Michel Mesquita, David O’Regan, Alessio Delogu, Ivan Chakalov, Andrea Antal, Allan H. Young, Romola S. Bucks, Melinda L. Jackson and Ivana Rosenzweig, 6 April 2023, Frontiers in Sleep.
The study was funded by the Wellcome Trust.