The Effect of CPAP in Normalizing Daytime Sleepiness, Quality of Life, and Neurocognitive Function in Patients with Moderate to Severe OSA
Open accessAbstract
STUDY OBJECTIVES: The study aimed to document the neurobehavioral outcomes of patients referred to and treated by a sleep medicine service for moderate to severe obstructive sleep apnea (OSA). In particular, we aimed to establish the proportion of patients who, while appearing to have optimal continuous positive airway pressure (CPAP) adherence, did not normalize their daytime sleepiness or neurocognitive function after 3 months of CPAP therapy despite effective control of OSA. DESIGN: Multicenter clinical-effectiveness study. SETTING: Three academic sleep centers in Australia. PARTICIPANTS: Patients referred to a sleep medicine service with moderate to severe OSA (n = 174). INTERVENTION: CPAP. MEASUREMENTS AND RESULTS: Participants were assessed pretreatment and again after 3 months of CPAP therapy. At the beginning and at the conclusion of the trial, participants completed a day of testing that included measures of objective and subjective daytime sleepiness, neurocognitive function, and quality of life. In patients with symptomatic moderate to severe OSA (i.e., apnea-hypopnea index > 30/h), we found a treatment dose-response effect for CPAP in terms of Epworth Sleepiness Scale scores (P < 0.001). Several key indexes of neurobehavior (e.g., Functional Outcomes of Sleep Questionnaire, Epworth Sleepiness Scale) currently used to assess treatment response failed to normalize in a substantial group of patients after 3 months of CPAP treatment, even in those who were maximally compliant with treatment. Forty percent of patients in this trial had an abnormal Epworth Sleepiness Scale score at the conclusion of the trial. In addition, we showed no dose-response effect with the Maintenance of Wakefulness Test, raising doubts as to the clinical utility of the Maintenance of Wakefulness Test in assessing treatment response to CPAP in patients with OSA. CONCLUSIONS: Our study suggests that a greater percentage of patients achieve normal functioning with longer nightly CPAP duration of use, but a substantial proportion of patients will not normalize neurobehavioral responses despite seemingly adequate CPAP use. It is thus crucial to adequately assess patients after CPAP therapy and seek alternate etiologies and treatments for any residual abnormalities.
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Current evidence suggests a continuous dose-response relationship between hours of PAP use and therapeutic response.
“current evidence suggests a continuous dose-response relationship between hours of use and therapeutic response.22,23”
From Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment (2019) · cites this paper as [22]
The Discussion passage (page not provided) reports a dose-response relationship for many, but not all, behavioral measures: it was clear for posttreatment ESS scores but absent for MWT sleep latency. Thus the paper supports a relationship between hours of CPAP use and some therapeutic outcomes, but not a continuous relationship across therapeutic response generally. (LLM, conf=0.87)
Experimental — accuracy not yet measuredMore time spent using CPAP leads to greater improvement in secondary manifestations of OSA such as sleepiness and quality of life.
“While more time spent using CPAP leads to greater improvement in secondary manifestations of OSA such as sleepiness and quality of life, the incremental improvements achieved with one extra hour of CPAP treatment are small [49,50].”
From Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: A randomized clinical trial (2019) · cites this paper as [50]
The Methodologic Considerations section reports significantly greater improvement in sleepiness (ESS) and disease-specific quality of life (FOSQ) with greater CPAP adherence. The ESS Scores section supports greater sleepiness benefit with increasing use, but its estimated FOSQ change of 0.149 points per additional hour was not statistically significant. The paper therefore does not establish the sentence’s broader implication that each extra hour produces a small improvement in both outcomes. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe incremental improvements achieved with one extra hour of CPAP treatment are small.
“While more time spent using CPAP leads to greater improvement in secondary manifestations of OSA such as sleepiness and quality of life, the incremental improvements achieved with one extra hour of CPAP treatment are small [49,50].”
From Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: A randomized clinical trial (2019) · cites this paper as [50]
In the ESS Scores section (page unavailable), the paper estimates a small FOSQ change of 0.149 points per additional hour of CPAP use, but says that association was not statistically significant. It reports greater ESS benefit with increasing use, without establishing that the sleepiness improvement from one extra hour is small. (LLM, conf=0.81)
Experimental — accuracy not yet measured
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- Authors
- Antic, N. A., Catcheside, P., Buchan, C., Hensley, M., Naughton, M. T., Rowland, S., Williamson, B., Windler, S., & McEvoy, R. D.
- Affiliations
- Flinders University (AU)
- The Alfred Hospital (AU)
- John Hunter Hospital (AU)
- Repatriation General Hospital (AU)
- Venue
- Sleep
- Publisher
- Oxford University Press (OUP)
- Published
- 2011-01
- Volume
- 34
- Issue
- 1
- Pages
- 111-119
- ISSN
- 0161-8105 (ISSN-L)
- 1550-9109
- PMC
- PMC3001789
- OpenAlex
- W199424036
- Cited by
- 533
- References
- 33
- Citations by year
- 2026: 17 · 2025: 21 · 2024: 26 · 2023: 36 · 2022: 56 · 2021: 45 · 2020: 50 · 2019: 41 · 2018: 43 · 2017: 39 · 2016: 36 · 2015: 38 · 2014: 27 · 2013: 31 · 2012: 16
- FWCI
- 18.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- SLEEP (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- NOVA (University of Newcastle Australia) (submittedVersion)
- Funders
- ResMed
- Masimo
- Medical Research Council
- National Health and Medical Research Council
- Topics
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and Work-Related Fatigue
- Keywords
- obstructive sleep apnea, CPAP therapy, daytime sleepiness, neurocognitive function, quality of life, Epworth Sleepiness Scale, maintenance of wakefulness test, CPAP adherence, treatment response assessment, dose-response relationship
- MeSH terms
- Cognition, Female, Humans, Male, Middle Aged, Neuropsychological Tests, Patient Compliance, Quality of Life, Surveys and Questionnaires, Sleep, Wakefulness, Treatment Outcome, Sleep Apnea, Obstructive, Continuous Positive Airway Pressure
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