The Psychosocial Aspects of Obstructive Sleep Apnea
In the recent past, studies on obstructive sleep apnea (OSA) have increased. According to Spicuzza, Caruso & Di Maria (2015), OSA is a respiratory condition where patients experience repeated episodes of breathing cessation at night while sleeping. Consequently, OSA causes myriad severe outcomes including cardiovascular morbidity, excessive daytime somnolence, and mortality. While OSA has been a difficult respiratory condition to handle, a raft of options exists today. However, not all the treatment options work for all individuals in the same way.
The gold standard of treating OSA is continuous positive airway pressure (CPAP). Other options are equally effective, but it particularly depends on the condition of the patient as well as the level of tolerance the patient can afford. This literature review investigates the psychosocial aspects of obstructive sleep apnea so as to open a lead to better treatment solutions of the condition.
Recent studies have concluded that obstructive sleep apnea has direct impact on cognitive, emotional and social life of the individual.
Besides, the impacts are not only in adults but also in children (Brown, 2005). With such devastating effects on the health of individuals, it becomes imperative to analyse and understand the causes, symptoms, and ways of treating obstructive sleep apnea. Most importantly, it is necessary to substantiate the extent to which these aspects affects children and adults in determining the quality of life and what can be done to alleviate the negative impacts. In an earlier study, Blunden, Lushington & Kennedy (2001), found out that obstructive sleep apnea had direct impact on cognitive and behavioural impact on children.
Such effects may have long standing implications given that respiration has a direct impact on the cognitive ability of an individual which starts developing at young age and goes on up to adulthood. If a child has OSA, then they are likely to fail in simple cognitive tasks at school and at home, making them less receptive to opportunities presented to them in life. On the other hand, Santana & Santana (2008) concluded that sleep apnea is a cause of erectile dysfunction in men. Therefore, whether in children or adults, OSA has grave implications on the overall quality of life of an individual and must be understood from onset through treatment until the patient is able to regain their normal life.
The Psychosocial Aspects of Sleep Apnea
The psychosocial aspects of sleep apnea are broad and cannot be exhaustively discussed. However, some are common and have attracted considerably high interest among physicians and research experts. In one of the recent studies about psychosocial aspects of OSA, Alkhalil, Schulman & Getsy (2009) linked OSA to asthma. According to them, OSA is associated with obstructed respiration, meaning that individuals with the problem develop asthma. Salles, Terse-Ramos, Souza-Machado & Cruz (2013) noted that, Symptoms of sleep-disordered breathing, especially obstructive sleep apnea syndrome (OSAS), are common in asthma patients and have been associated with asthma severit (p.604). This means that OSA has a positive correlation with the severity of asthma. While discussing about the relationship between asthma and OSA, both Alkhalil et al. (2009) and Salles et al. (2013) agree that OSA is an independent factor in the onset and exacerbation of asthma. However, Dixit (2018) presents a contrary view stating categorically that both OSA and asthma influence the severity of each other depending on which condition developed first. According to Salles et l. (2013) Asthma is a chronic inflammatory disease with multiple phenotypes related to genetic predisposition and various environmental interactions, and there is still a major gap in the understanding of its complex causality and, consequently, in the primary prevention of the disease (p.605). That implies that asthma develops on its own and that OSA is an independent factor in its exacerbation. The same applies to OSA, which not only affects asthma patients but any individual predisposed by any other factor.
While numerous studies link OSA to the onset and development of asthma in human beings, another recent study, Prasad (2013), found out that the relationship between asthma and OSA is not only what scientists believe. Instead, Prasad (2013) introduces a different view by introducing a new parameter. Prasad (2013) also links high rates of OSA to obesity, which implies that the severity of asthma influenced by OSA will be different in individuals based on whether they are obese or non-obese. Therefore, understanding the pathophysiology of OSA in both obese and non-obese populations is quintessential for the management and treatment of the disease. Prasad (2013) goes further to highlight that male sex, age, hereditary factors, and craniofacial anatomical disposition as the risk factors to the onset and development of OSA. Therefore, it implies that obese males are more predisposed to OSA than any other category of human beings. These findings by Prasad (2013) are supported by Dixit (2018) who claimed that there is a bidirectional relationship between asthma and OSA and therefore each disorder severely affects the other.
While discussing the psychosocial aspects of OSA, Brown (2005), explains that OSA is characterized by the following symptoms: hypoxemia, sleeps deprivation, and sleep fragmentation. Sarkar, Niranjan & Banyal (2017) defines hypoxemia as a condition where the blood has abnormally low levels of oxygen causing hypoxia. On the other hand, hypoxia is a reduced level of tissue oxygenation. Hypoxemia is caused by respiratory problems, OSA being one of them. Subsequently, hypoxemia causes hypoxia, which leads to respiratory problems such as asthma. Brown (2005) highlighted that the brain has less than 2% of the total body weight but requires more than 20% of the total oxygen intake and 15% of cardiac output. Based on these statistics, it is apparent that hypoxemia has intrinsic relational capacity with OSA. Besides, the impacts of hypoxemia on body function reveal that the brain is a very sensitive organ and any interruptions in its metabolism leads to an assortment of body system malfunction that reveal in myriad other ways. The other symptoms of sleep deprivation, and sleep fragmentation are superficial and they point towards hypoxemia.
Brown (2005) goes further to explain the results of obstructed sleep apnea citing eventual poor quality of life. In his words, Brown (2005, p.33) states that The primary events of obstructed breathing during sleep, snoring and obstruction of the upper airway, cause hypoxemia, sleep fragmentation, and daytime sleepiness. As already discussed in the preceding paragraphs, it is apparent that individuals with OSA do not enjoy life since there are conditions that take advantage of the inability to breathe well. Some of the conditions have been discussed and asthma is one of them. However, Brown (2005) highlights that both adults and children end up experiencing cognitive, emotional and social problems as far as OSA is concerned. While some changes in the cognitive ability of individuals may be permanent, Brown (2005) states that they are mostly mild especially if treatment is administered properly. However, Brown (2005) goes ahead to state that even mild apnea can affect the quality of life severely causing depression. The findings by Brown (2005) are supported by those of Shoib, Malik & Masoodi (2017) who found out that depression is a manifestation of OSA. However, the study by Shoib, Malik & Masoodi (2017) revealed that there is a significant overlap of depression and OSA, and that further studies need to be conducted so that the clear-cut explanation can be obtained for the sake of proper treatment.
Psychosocial aspects of OSA and Effect on Quality of Life
Traditional studies have linked obstructive sleep apnea to mortality and morbidity (Brown, 2005). However, the traditional studies have remained to be the gold standard of understanding the overall impact of OSA on the quality of life since even recent studies confirm that OSA indeed negatively affects the life of individuals who suffer from it. According to Coman, Borzan, Vesa & Todea (2016, p.390), Obstructive sleep apnea syndrome (OSA) affects the quality of life (QOL) due to the effects on the patients physical and mental function. While investigating the correlation between the changes in the severity of OSA and the quality of life of patients, Baflah (2016) established that when patients with OSA are put on treatment, their overall quality of life improved with less stress and reduced depression leading to better quality of life. The converse was true. In another but significantly focused study of the immune system of individuals with OSA versus those without, Xie, Yin, Bai, Peng, Zhou & Bai (2018) established that OSA patients have lower immunity than those without. Therefore, it is apparent from the two studies that OSA patients have a high rate of depression as well as high predisposition to contracting other ailments.
Perhaps Brown (2005) provides the best nuanced and focused view of the psychosocial aspects of OSA on individuals. While discussing the impacts of OSA on the quality of life, Brown (2005) concluded that OSA has adverse psychological consequences at work and at home. One of the symptoms, of OSA is snoring and it has a negative impact on spousal relationship sometimes leading to them sleeping in separate bedrooms (Brown, 2005). Primarily, what Brown (2005) informs is that while there are negative health outcomes of OSA, there are also social problems that arise and significantly affect how close family members relate with the individual who is suffering from OSA.
In a study aimed at understanding the differences between males and females, OSA and the quality of life, Silva, Goodwin, Vana & Quan (2016, p.137) found out that: The impact of OSA on quality of life differs between genders with a larger effect on females and is largely explained by the presence of daytime sleepiness. Correlations among quality of life instruments are not high and various instruments may assess different aspects of quality of life. The findings by Silva et al. (2016) show that OSA is a very complex concept and more studies need to be done so as to substantiate: its real aspects, the disposing factors, gender differences, and outcomes as well as the impact on quality of life. Besides, it is likely that there are racial differences in how quality of life is affected among people of different habitation.
In their study, Silva et al. (2016) accept that studies on the impact of OSA on quality of life are well documented. However, they also warn that there has been a long standing problem when it comes to determining the right tools for measuring the quality of life. In their study, Silva et al. (2016) used the 36-item Short Form of the Medical Outcomes Survey (SF-36) and compared the results obtained using the Calgary Sleep Apnea Quality of Life Index (SAQLI). They also used the Functional Outcomes Sleep Questionnaire (FOSQ) in persons with OSA. On the other hand, Shoib et al. (2017) performed polysomnography (PSG) studies of patients from various hospitals over a period of two years 2011 to 2013. They later applied the Hamilton Depression rating Scale (HAM-D) and used statistical methods to analyse the data. Other studies employ methods that are differentiated as far as measuring quality of life in patients with OSA is concerned. Therefore, there is need for a standard measuring tool as far as measuring quality of life in clinical studies is concerned. However, FOSQ and PSG are characteristically favoured in most studies that seek to evaluate the quality of life of patients with OSA and associated conditions.
Resolving the Psychosocial Aspects of OSA
The literature on treatment and management of OSA is broad and almost unified. According to Brown (2005), decades of research have helped develop standard methods of treating OSA with success. Such approaches include continuous positive airway pressure (CPAP), nasal CPAP (nCPAP), and surgery. CPAP remains to be the gold standard in treating OSA, especially where the patient cannot withstand the harsh impacts of nCPAP. Similarly, Min & Kim (2015) discussed medical management of OSA and suggested some of the following approaches: positive airway pressure (PAP), continuous positive airway pressure (CPAP), and Bi-level PAP for patients that cannot tolerate CPAP. CPAP is the first level management technique for both mild and acute OSA. There are also other treatment options available to OSA patients where advanced mandibular tools are used. However, Brown (2005) categorically states that the role of surgery is under review and its effectiveness is questionable despite the growing research interest. Most importantly, Brown (2005), states that the management of OSA requires a multi-disciplinary approach for effectiveness.
On his part, Kryger & Malhotra (2017) suggests a raft of readily available measures to manage OSA that include: educating patients on good lifestyle, behaviour modification, weight loss and exercise, sleep position, alcohol avoidance, and concomitant medications. The methods discussed by Kryger & Malhotra (2017) remain non-invasive and give the patient the option of dealing with a personal problem through body regulation. Kryger & Malhotra (2017) focused their research on determining the best approach in resolving OSA in adults. According to them, the primary role of OSA management and treatment is to alleviate the symptoms, improve sleep quality and improve the overall quality of life. Therefore, in suggesting the behavioural approaches, Kryger & Malhotra (2017) acknowledged that adults have complete control over their lives and should act as so. In the words of Kryger & Malhotra (2017, p.8), OSA should be approached as a chronic disease that requires long-term, multidisciplinary management. This therefore implies that OSA requires long term management strategies since it is a condition and not a disease which can be treated using antibiotics.
Just like Kryger & Malhotra (2017), Hofauer, Steffen, Knopf, Hasselbacher, & Heiser (2018), highlight that OSA can be treated by upper airway simulation instead of concomitant medication. Concomitant medications are drugs that are characteristically administered at the same time. However, the use of drugs has for some time been an issue of concern given that some patients may not be ready to take bitter pills and sticking to schedules is may be difficult. Kryger & Malhotra (2017) states that some of the benefits that arise out of successful treatment of OSA include reduced cost of healthcare services, better and quality sleep and day time alertness. Besides, it ensures decreased mortality as well as cardiovascular morbidity. Therefore, with better treatment options that are available today, OSA clinicians should be able to help patients regain their better quality of life through good treatment.
In summary, there is broad literature on OSA, its psychosocial aspects, how it affects the quality of life, and its treatment and management. From the literature, it is evident that the psychosocial aspects of OSA are not sufficiently addressed in the existing literature, leaving a gap into the set of knowledge for a more elaborate explanation. The term psychosocial is used to mean the interaction of social factors and individuals through thought and behaviour. Thus, most studies on the psychosocial aspects of OSA fail to clearly distinguish between the psychosocial aspects that are evident in individuals as a result of other conditions from those caused by OSA. A good example of where the blurring effect is evident is when asthma and OSA are evaluated together. The existing literature reveals that asthma is exacerbated by OSA and vice versa. Similarly, the psychosocial effects of asthma and those of OSA are almost the same, yet the two conditions are totally different in terms of all the aspects that define them. Besides, the literature reveals that OSA is a predisposing factor of asthma and vice versa. Based on such findings, it is possible to misunderstand the psychosocial aspects of OSA by defining those of other related conditions. Therefore future research needs to remove this blurring effect and replace it with a clear cut explanation of the true aspects of OSA.
Besides the problem of defining the psychosocial aspects of OSA, the determination of quality of life is marred with a confusion regarding the rightful instruments to use in measuring quality of life. The use of PSG may be universal, but it requires experiments set in a longitudinal style to examine patients and still does not provide data that is reliable for all cases of OSA. Other tools such as HAM-D and SAQLI remain subjective given the nature of experiments in which they are used. Perhaps the most well defined issue in recent studies about OSA is the treatment and management. In most of the studies, CPAP and related approaches have been held in high regard and accepted as the modern and most reliable methods of treating and managing OSA. Therefore, future studies must focus on proper definition of the psychosocial aspects of OSA, the methods of measuring quality of life in OSA patients, and the key predisposing factors that differentiate OSA from asthma.