Effects of Obstructive Sleep Apnea on Sleep Quality, Cognition, and Driving Performance in Patients With Cirrhosis

Abstract

Background & Aims: In patients with cirrhosis, sleep disturbances are assumed to result from hepatic encephalopathy (HE). The effects of obstructive sleep apnea (OSA) on cognition, sleep parameters, or driving in patients with cirrhosis are unclear. Methods: We performed a cross-sectional, prospective study of 118 subjects. Subjects were assigned to 1 of 4 groups: those with OSA and cirrhosis (without HE or ascites, n=34), those with only cirrhosis (n=30), those with only OSA only (n=29), and those without OSA or cirrhosis (controls, n=25). None of OSA patients were receiving continuous positive airway pressure (CPAP) therapy. Subjects underwent cognitive testing (paper–pencil tests for psychomotor speed and attention, as well as executive function tests), sleep assessment (daytime sleepiness and night-time sleep quality) and a monotonous driving simulation (worsening lane deviations over time indicate poor performance). We also tested patients with OSA, with cirrhosis (n=10) and without cirrhosis (n=7), before and after CPAP therapy. Results: Daytime sleepiness and sleep quality were worse in subjects in the OSA groups (with or without cirrhosis) than subjects with cirrhosis alone or controls. Of subjects with only OSA, 36% had impaired psychomotor speed and attention, compared to >60% of subjects in both cirrhosis groups. In contrast, executive function was uniformly worse in subjects with OSA, with or without cirrhosis, than groups without OSA. Simulator performance (lane deviations) worsened over time in both OSA groups. CPAP therapy significantly increased executive function and sleep quality, and reduced simulator lane deviations and sleepiness, in subjects with and without cirrhosis. After CPAP therapy, performance on the paper–pencil test performance improved significantly only in subjects with OSA without cirrhosis. Conclusion: OSA should be considered in evaluating sleep impairment in patients with cirrhosis. In patients with cirrhosis and OSA, psychomotor speed and attention issues are likely related to the cirrhosis, whereas executive function and simulator performance are affected by the OSA. CPAP therapy improves executive function and simulator performance in patients with OSA, regardless of cirrhosis.

Sleep disturbances in patients with liver cirrhosis: prevalence, impact, and management challenges

“…Indeed, Bajaj et al have observed EDS and poor quality of sleep in compensated cirrhotics compared to healthy controls. 10 Comparison of sleep in cirrhosis with prior HE vs without prior HE has also highlighted a further deterioration of sleep quality, with more non-restorative sleep. 11 Etiology of cirrhosis does not influence the occurrence/the clinical picture of sleep disturbances that have been observed both in series of patients affected exclusively or mainly by hepatitis C 2 , 10 , 11 , 12 and in series including a majority of alcoholic cirrhosis.…”

How frequent is sleep-disordered breathing among Egyptian cirrhotic adults?

“…OSA is associated with elevated alanine aminotransferase levels and a trend toward histologic evidence of progressive liver disease [ 22 ]. A small sample size study of 17 patients showed improvement in executive functions after continuous positive airway pressure (CPAP) treatment of OSA, which was in turn an independent predictor of concomitant liver cirrhosis [ 23 ]. An interesting study found that chronic intermittent hypoxia in mice with induced obesity is associated with liver fibrosis due to activation of pro-inflammatory pathways of liver fibrosis [ 24 ].…”

Symptom Domain Groups of the Patient-Reported Outcomes Measurement Information System Tools Independently Predict Hospitalizations and Re-hospitalizations in Cirrhosis

“…These findings point toward the importance of assessing daily function concerns at each clinical visit, both physical and mental, along with communicating the plan of care with patients and their family members. Examples of this would be addressing nutritional status to improve sarcopenia and muscle strength [36], and sleep disturbances which can be a sign of impending HE [37] or undiagnosed obstructive sleep apnea [38].…”