Current treatment options for OSA include both non-pharmacologic and pharmacologic modalities (Table 1).
It is thought that tricyclic antidepressants (TCAs) improve OSA by increasing rapid eye-movement (REM) sleep latency while decreasing the overall amount of time spent in REM sleep. The selective serotonin reuptake inhibitors (SSRIs) are thought to increase upper airway muscle tone in addition to increasing the amount of serotonin in the brain, which can improve sleep apnea by stimulating the hypoglossal motoneurons.
Oral therapy with leukotriene antagonists has been moderately successful in children with sleep-disordered breathing due to the dominant expression on their tonsils of cysteinyl leukotriene receptors (LT1-R and LT2-R) in T lymphocytes without increased serum levels of C-reactive protein. Menopause is considered a risk factor for snoring and sleep-disordered breathing that is thought to result from a loss of the protective effects of female hormones. Stimulant medications may be beneficial in reducing the excessive sleepiness associated with OSA.
Additional therapies that have been studied in the treatment of sleep apnea include testosterone, agents for acromegaly, opiate antagonists, antihypertensives, glutamate antagonists, acetazolamide, physostigmine, tumor necrosis factor (TNF)-alpha agonists, and carbon dioxide inhalation. Patients with obstructive sleep apnea (OSA) are likely to develop cognitive impairments, including problems with concentration, memory, and executive function. Obstructive sleep apnea (OSA) is caused by a narrowing of the upper airway during sleep, resulting in complete (apnea) or partial (hypopnea) cessations of breathing.
Primary care physicians (PCPs) play a key role in recognizing symptoms and risk factors associated with OSA, as well as longitudinal management of the disorder; however, little has been published regarding cognitive dysfunction in the primary care population. Hypoxia, sleep fragmentation, and excessive sleepiness are all thought to contribute to neurocognitive deficits in patients with OSA (Table 2). It may seem obvious that sleep fragmentation occurs in patients with OSA and that fragmented sleep can lead to daytime sequelae, predominantly excessive sleepiness. The effects of sleep fragmentation have been examined in a study50 that controlled for total sleep time in five healthy subjects who experienced three different rates of experimentally induced fragmented and nonfragmented sleep. It would be reasonable to expect that if the cognitive deficits associated with OSA were primarily due to sleep fragmentation or excessive sleepiness, these issues would quickly remit with effective treatment for OSA. Some researchers have suggested that both hypoxia and sleep fragmentation play a role in cognitive impairment in patients with OSA and that the severity of these deficits is likely to depend on the severity of OSA, the degree of hypoxia, and the susceptibility of the patient.
Sleep apnea, a disruption of breathing while asleep, is a particularly tricky sleep disorder – 90% of people who have sleep apnea don’t know that they have it! Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. Sleep apnea is very common, as common as adult diabetes, and affects more than twelve million Americans, according to the National Institutes of Health.
A simple test can be taken that will grade this last symptom called the Epworth Sleepiness Scale, as well as a Sleep Observers Questionnaire, which should be filled out by anyone who regularly observes the potential sleep apneic. Snoring does often accompany sleep apnea, but just because you snore does not mean you have sleep apnea.
These appliances reduce sleep apnea associated health risks without the need for surgery, medications, or other therapies. When you have obstructive sleep apnea, your throat collapses during sleep, blocking the airway and preventing air from getting to the lungs. Family history of sleep apnea – No specific genetic marker for sleep apnea has been discovered, but obstructive sleep apnea seems to run in families. If you have sleep apnea, you stop breathing during sleep, and the balance of oxygen and carbon dioxide in the blood is upset. Some trickle-down effects of sleep deprivation are a compromised immune system, poor mental and emotional health, irritability, and slower reaction time, among other problems. Approximately one in five people who suffer from depression also suffer from sleep apnea, and people with sleep apnea are five times more likely to become depressed. For a dentist to diagnose sleep apnea they will examine your mouth and nose to look for obstructions as well as studying x-rays, or a CT scan of the head and neck.
If your dentist suspects sleep apnea, he or she will likely recommend an overnight sleep study. Polysomnography is the diagnostic test that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, air flow, and blood oxygen levels.
The clinically validated treatment for sleep apnea and snoring that fits in the palm of your hand. Unlike other snoring treatment devices on the market, the SomnoDent MAS™ is a precision instrument which is custom designed for each person to help them stop snoring. The SomnoDent MAS™ is an effective treatment both mild to moderate obstructive sleep apnea. OSA is characterised by repeated cycles of partial or complete collapse of the upper airway during sleep.
The SomnoDent MAS™ has helped people who have tried other OSA treatments and been unsuccessful or have not complied with their CPAP treatment. The American Academy of Sleep Medicine recommend oral appliances as a first line treatment for snoring and mild to moderate OSA.
It is highly effective (in most cases) in stopping snoring and treating obstructive sleep apnea in the mild to moderate range. The patented fin-coupling mechanism on the lower arch of the SomnoMed splint ensures that your lower jaw (mandible) remains in the correct position, whether you sleep with your mouth open or closed – or open your mouth for any other reason, such as to take a drink. Sometimes when we sleep, the muscles that hold the airway open relax and partially collapse, obstructing the flow of air slightly. The SomnoDent MAS™ is for the effective treatment of snoring and for the more serious condition of obstructive sleep apnea. Snoring may however, be the sign of a serious condition known as Obstructive Sleep Apnea (OSA).
Most of us don’t think of snoring as something to be overly concerned about unless our bed partner is disrupting our sleep! This chronic sleep deprivation results in: Daytime sleepiness, Slow reflexes, Poor concentration & increased risk of accidents.
Sleep apnea can also lead into serious health problems over time, Such as: Diabetes, High blood pressure, Heart disease, Stroke & weight gain. With the proper treatment, you can control these symptoms, get your sleep back on track, & start enjoying what it’s like to be refreshed and alert every day.
This modification to sleep architecture possibly improves OSA since the condition worsens during REM sleep, especially in overweight patients.

Pharmacists should recommend discontinuation of medications that can have a negative impact on the treatment of OSA.
The etiology of these deficits is not fully resolved, although sleep fragmentation, excessive sleepiness, and hypoxemia appear to interact to produce neurologic consequences in patients with OSA. OSA is characterized by chronically fragmented sleep, intermittent reductions in blood-oxygen levels (hypoxemia), and resultant low oxygen supply to the tissues (hypoxia). This article examines the evidence that patients presenting in the primary care setting with cognitive deficits of unknown origin may have OSA and, therefore, require further assessment. However, there are few studies demonstrating the relationship between sleep fragmentation and excessive sleepiness by the induction of sleep fragmentation in normal controls.
In all cases, two consecutive nights of fragmentation resulted in objective sleepiness regardless of the fragmentation schedule used, suggesting that even moderately fragmented sleep has deleterious consequences. The first study51 induced sleep fragmentation by presenting audible tones to eight normal subjects during sleep. Further work is clearly required in this area in order to determine the impact of excessive sleepiness. PAP treatment reduces hypoxia, normalizes blood-oxygen saturation, and reduces sleep fragmentation, thereby improving a majority of the effects of OSA. However, current evidence indicates that hypoxia is partially responsible for this impairment and that its effects are not responsive to treatments for OSA. A proportion of the clinical impairment seen in patients with OSA can be attributed to eroded vigilance and attention due to daytime sleepiness caused by sleep fragmentation. Relationship between quality of life and mood or depression in patients with severe obstructive sleep apnea syndrome. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Neuropsychological sequelae of obstructive sleep apnea-hypopnea syndrome: a critical review. The neuropsychological effects of obstructive sleep apnea: A meta-analysis of norm-referenced and case-controlled data. Obstructive sleep apnea and the prefrontal cortex: Towards a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioural deficits. Cognitive deficits associated with sleep apnea syndrome: a proposed neuropsychological test battery. Nocturnal sleep apnea-hypopnea is associated with lower memory performance in APOE ε4 carriers. Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome. Impairment of endothelium-dependent vasodilation of resistance vessels in patients with obstructive sleep apnea.
Sleep deprivation decreases superoxide dismutase activity in rat hippocampus and brainstem.
Neuropsychological investigations and event-related potentials in obstructive sleep apnea syndrome before and during CPAP-therapy. Cognitive function in middle-aged snorers and controls: role of excessive daytime somnolence and sleep-related hypoxic events. Hippocampal area metabolites relate to severity and cognitive function in obstructive sleep apnea.
Long-term intermittent hypoxia in mice: Protracted hypersomnolence with oxidative injury to sleep-wake brain regions. Sleep fragmentation in normals: A model for sleepiness associated with upper airway resistance syndrome. Neuropsychological functioning and determinants of morning alertness in patients with obstructive sleep apnea syndrome.
Neuropsychological function in obstructive sleep apnea syndrome (OSAS) compared to chronic obstructive pulmonary disease (COPD).
Persistent neuropsychological deficits and vigilance impairment in sleep apnea syndrome after treatment with positive airway pressure (CPAP). Cognitive function in patients with sleep apnea after acute nocturnal nasal continuous positive airway pressure (CPAP) treatment: Sleepiness and hypoxia effects.
Neuropsychological effects of one-week continuous positive airway pressure treatment in patients with obstructive sleep apnea: a placebo-controlled study.
Cognitive dysfunction in patients with obstructive sleep apnea (OSA): Partial reversibility after continuous positive airway pressure (CPAP). Neuropsychological effects of 2-week continuous positive airway pressure treatment and supplemental oxygen in patients with obstructive sleep apnea: a randomized placebo-controlled study.
Cognitive executive dysfunction in patients with obstructive sleep apnea syndrome (OSAS) after CPAP treatment.
Improvement in neuropsychological performance following surgical treatment for obstructive sleep apnea syndrome. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Persistent sleepiness in CPAP treated obstructive sleep apnea patients: evaluation and treatment. Armodafinil improves wakefulness and long-term episodic memory in nCPAP-adherent patients with excessive sleepiness associated with obstructive sleep apnea. Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea: a 12-week, open-label study. In central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to breathe.
Risk factors include being male, overweight, and over the age of forty, but sleep apnea can strike anyone at any age, even children. Not all apneics will score high, but if you do, it is a very good sign of OSA (obstructive sleep apnea). Snoring is simply a loud sound that you make during breathing while asleep if there is any obstruction in your airway.
Dentists now can provide you with a home monitor to help you (and us) assess whether or not sleep apnea should be a concern. If you are one of the non-compliant, we can fabricate an oral appliance that will help open your airway and reduce the severity of your sleep apnea.

A bed partner may lose an hour or more of sleep each night from sleeping next to a person with sleep apnea. These episodes of obstruction , and resultant awakening of the OSA sufferer occur five or more times per hour, potentially causing marked sleep disruption. Where there is complete collapse, you have an incidence of sleep apnea, which is when breathing stops altogether.
While not everyone who snores suffers from obstructive sleep apnea, SomnoMed suggests that if you have been heard to gasp for breath or have sudden spells of drowsiness during the day, then you should obtain a referral to a qualified specialist.
In untreated sleep apnea, breathing is briefly interrupted or becomes very shallow during sleep.
It occurs when the soft tissue in the back of your throat relaxes during sleep, causing a partial or complete blockage of the airway.
A one-month, double-blind, placebo-controlled study of donepezil in OSA patients found an improvement in AHI, oxygen saturation, and REM sleep. Despite numerous trials, CPAP has demonstrated greater efficacy as compared to drug therapy, and the role of pharmacologic treatment may be as adjunctive therapy, not as monotherapy. The relative roles of sleep fragmentation, excessive sleepiness, and hypoxemia in the development of neurologic sequelae remain unclear. To this end, the article discusses the neurocognitive deficits associated with OSA and considers the current evidence concerning potential mechanisms for cognitive dysfunction in this patient population, paying particular attention to the roles of higher executive injury due to hypoxia and reduced alertness due to sleep fragmentation and excessive sleepiness. A comprehensive meta-analysis49 has concluded that a strong linear relationship exists between the rate of sleep fragmentation and the level of objective sleepiness. The tones were designed and delivered to disrupt nocturnal sleep architecture; sleepiness and performance were then measured the next morning. It is thought that improvements in daytime vigilance following treatment with PAP may account, in part, for recovery in other cognitive domains.57,58 Several studies8,57,59-62 have reported improvements across multiple domains of cognitive functioning following treatment with PAP. Furthermore, there is emerging evidence that hypoxia may also cause excessive sleepiness by damaging wake-active areas of the brain. While it may be unpleasant for your sleep partner, snoring is not in itself a harmful condition.
The gold standard for treatment of sleep apnea was for a long time the CPAP machine, however, in many cases it is now an oral appliance.
Along with the apnea episodes, the person afflicted with sleep apnea may have additional trouble sleeping caused by side effects of the condition, including a frequent need to get up and urinate during the night, and excessive nighttime sweating.
While it is not clear whether the apnea causes the depression or vice-versa, studies show that by treating sleep apnea symptoms, depression may be alleviated in some people. These sleep tests provide the information needed to diagnose sleep apnea by measuring how frequently you stop breathing. Treatment goals include reducing risk factors for OSA, correcting underlying metabolic disorders, treating the consequences, and preventing episodes of apnea and hypopnea. A pilot study of TNF-alpha agonists did demonstrate reduced AHI and reduced sleepiness, but further studies would be required to establish their benefit in OSA. Future pharmacologic therapies should be developed toward addressing the daytime sleepiness and fatigue associated with OSA.
Many patients with OSA will present in the primary care setting and may not know that they have a sleep disorder. The investigators47 suggested that the increase in sleep fragmentation could have dramatic effects on daytime sleepiness, though they did not specifically suggest a direct connection with hypoxia. Slow-wave non-rapid eye movement (non-REM) sleep was significantly decreased when participants were subjected to sleep fragmentation and REM sleep was also moderately decreased.
However, the same studies also illustrate that deficits in executive functioning and constructional abilities, short-term memory, and manual dexterity persist after PAP treatment and may be associated with irreversible damage to the brain in response to long-term hypoxia. Low efficacy and the discomfort associated with surgery have decreased the popularity of UPPP as a first-line treatment for OSA in favor of PAP. With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality. On the other hand, people with sleep apnea are deprived of oxygen due to a complete blockage of airways, which can have a major impact on health. Treatment of obesity and underlying metabolic disorders would prove beneficial to this patient population. Vigilance for the cognitive symptoms of OSA could assist in recognition by primary care physicians and aid in the prevention of lasting neurocognitive sequelae in this patient population. Complete resolution of all sequelae by PAP treatment may not, therefore, be possible in all patients exposed to previously unrecognized hypoxia, emphasizing the importance of early diagnosis and treatment of OSA.
These waking episodes are necessary to restart breathing (and to save your life), but because of them, you become sleep-deprived.
The MSLT is used most commonly to determine the severity of excessive sleepiness associated with sleep apnea or narcolepsy by measuring the difference in time between lying down and the time at which a person falls asleep during the daytime over multiple 20-minute intervals.
It should be noted that all of the studies described in this article consisted of patients seen in sleep clinics as opposed to primary care settings. The authors hope that the information provided can aid in the identification of cognitive dysfunction in primary care with the understanding that these cognitive problems may have a multitude of mechanisms. Participants demonstrated shorter sleep latencies on the MSLT the following day, attesting to their increased sleepiness; however, performance testing results did not suffer.
Recognition of sleep apnea as a primary mechanism is imperative, as has been highlighted here. A second study52 examined the effects of sleep fragmentation without disrupting sleep architecture.
A high level of awareness among PCPs for these cognitive sequelae also plays an instrumental role in the recognition and diagnosis of this sleep disorder and may allow early appropriate intervention and the minimization of hypoxic brain damage. In this unique and elegant study, investigators presented auditory tones that were designed not to induce arousals from sleep but rather to modify autonomic response (eg, increase heart rate and blood pressure) in the absence of obvious brain arousals as assessed by electroencephalography. The results of this study also showed that slow-wave sleep was reduced by sleep fragmentation and excessive sleepiness was increased. To date, there have been no studies examining the degree to which individuals are able to accommodate sleep fragmentation after repeated nights of exposure.

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Comments Treatment of obstructive sleep apnea in primary care

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