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July 26, 2022; 99 (4) Research Article

Positive Airway Pressure and Cognitive Disorders in Adults With Obstructive Sleep Apnea

A Systematic Review of the Literature

Monica Moon Shieu, Afsara Binte Zaheed, Carol Shannon, Ronald David Chervin, Alan Conceicao, Henry Lauris Paulson, Tiffany Joy Braley, Galit Levi Dunietz
First published May 6, 2022, DOI: https://doi.org/10.1212/WNL.0000000000200383
Monica Moon Shieu
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Afsara Binte Zaheed
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Carol Shannon
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Ronald David Chervin
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Alan Conceicao
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Henry Lauris Paulson
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Tiffany Joy Braley
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Galit Levi Dunietz
From the Department of Neurology (M.M.S., R.D.C., A.C., T.J.B., G.L.D.), Division of Sleep Medicine, Department of Psychology (A.Z.), Taubman Health Sciences Library (C.S.), Department of Neurology (H.L.P.), Division of Cognitive Disorders, and Department of Neurology (T.J.B.), Division of Neuroimmunology & Division of Sleep Medicine, University of Michigan, Ann Arbor.
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Positive Airway Pressure and Cognitive Disorders in Adults With Obstructive Sleep Apnea
A Systematic Review of the Literature
Monica Moon Shieu, Afsara Binte Zaheed, Carol Shannon, Ronald David Chervin, Alan Conceicao, Henry Lauris Paulson, Tiffany Joy Braley, Galit Levi Dunietz
Neurology Jul 2022, 99 (4) e334-e346; DOI: 10.1212/WNL.0000000000200383

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Abstract

Background and Objectives Alzheimer disease (AD) and other forms of dementia represent a rising global public health crisis. Because effective treatments to prevent, cure, or slow progression of dementia are unavailable, identification of treatable risk factors that increase dementia risk such as obstructive sleep apnea (OSA) could offer promising means to modify dementia occurrence or severity. Here, we systematically reviewed the impact of positive airway pressure (PAP) therapy on the incidence of cognitive disorders and cognitive decline among middle-aged and older adults with OSA.

Methods We performed a systematic search of MEDLINE, EMBASE, Scopus, and CINAHL before May 2021 to identify articles that focused on associations between PAP therapy use and cognitive disorders. We included studies that examined the effects of PAP treatment on (1) the incidence of cognitive disorders among individuals ≥40 years of age diagnosed with OSA and (2) the progression of cognitive decline among people with preexisting cognitive disorders and OSA.

Results We identified 11 studies (3 clinical trials and 8 observational studies). In these studies, 96% participants had OSA (n = 60,840) and 9% had baseline cognitive impairment (mild cognitive impairment [MCI] or AD) (n=5,826). Of all study participants, 43,970 obtained PAP therapy, and 16,400 were untreated or in a placebo group. Nine out of 11 studies reported a protective effect of PAP therapy on MCI and AD incidence, e.g., delayed age at MCI onset, reduced MCI or AD incidence, slower cognitive decline, or progression to AD.

Discussion These findings suggest a role for OSA as a modifiable risk factor for cognitive decline. Identification of modifiable risk factors is imperative for alleviating the impact of cognitive disorders on aging adults and their family members. Future research should build on this review and focus on PAP interventions as a potential means to alleviate the incidence of cognitive disorders and cognitive decline, particularly among ethnoracial groups who have been underrepresented and underinvestigated in the extant literature.

Glossary

AD=
Alzheimer disease;
AHI=
apnea-hypopnea index;
DNOS=
dementia not otherwise specified;
ICD=
International Classification of Diseases;
MCI=
mild cognitive impairment;
OR=
odds ratio;
OSA=
obstructive sleep apnea;
PAP=
positive airway pressure;
RCT=
randomized controlled trial;
WMH=
white matter hyperintensities

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Submitted and externally peer reviewed. The handling editor was Barbara Jobst, MD, PhD, FAAN.

  • Podcast: NPub.org/Podcast9828

  • Received October 5, 2021.
  • Accepted in final form February 25, 2022.
  • © 2022 American Academy of Neurology
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Letters: Rapid online correspondence

  • Reader Response: Positive Airway Pressure and Cognitive Disorders in Adults With Obstructive Sleep Apnea: A Systematic Review of the Literature
    • Tomoyuki Kawada, Professor, Nippon Medical School
    Submitted July 07, 2022
  • Reader Response: Positive Airway Pressure and Cognitive Disorders in Adults With Obstructive Sleep Apnea: A Systematic Review of the Literature
    • Steven Brenner, Retired Neurologist, Saint Louis University Neurology Dept. (retired)
    Submitted May 27, 2022
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  • Alzheimer's disease
  • Sleep apnea
  • Cognitive aging
  • MCI (mild cognitive impairment)

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