Screening for Obstructive Sleep Apnea in the Long-Term Care Setting

Abstract

<h3>Introduction</h3> Obstructive sleep apnea (OSA) is a primary sleep disorder that is characterized by partial or complete airway obstruction secondary to airway collapse. It results in momentary periods of involuntary respiratory cessation during sleep causing intermittent hypoxia and oxidative stress (1). It is also recognized as a risk factor for medical comorbidities such as hypertension, diabetes, and strokes (1). Furthermore, OSA is thought to be an independent risk factor for mental illnesses such as depression and cognitive impairment and can mirror or worsen symptoms of neurocognitive disorders like Alzheimer's disease (2). OSA is thought to increase the risk of Alzheimer's disease, while patients with Alzheimer's may have an elevated risk of developing OSA which in turn might contribute to a quicker progression of their cognitive decline (3). The primary objective of this study is to determine if a correlation between OSA and declining cognitive functions exists among patients in long-term care facilities. Compared to the general population who reside in community settings, sleep disturbances are more common and more severe in patients who are in nursing homes (4). Few studies have investigated the prevalence of OSA in long-term care among residents in skilled nursing facilities. It is important to screen both cognitively impaired and intact individuals for OSA in the long-term care setting. Prompt screening and diagnosis with subsequent initiation of appropriate treatment may result in reversal and/or resolution of cognitive changes associated with this disorder and improve the patients' overall functionality and quality of life (5). <h3>Methods</h3> This is an investigator-initiated, observational cross-sectional study. Subject enrollment took place during June 2019 - November 2021. No randomization was required. We utilized 2 scales: a brief and practical questionnaire called the STOP-BANG to screen for OSA with scores of 3-4 conferring intermediate risk while scores of 5-8 considered high risk for OSA. The Saint Louis University Mental Status (SLUMS) examination was used to determine cognitive status with higher scores correlating with better cognition. Data acquired was compared between residents who suffered from impaired cognition with those who were cognitively intact. No treatment or intervention was administered to patients. Long-term care residents and their families were approached for consent to participate in the study. The study was approved by the St. Louis University School of Medicine IRB. Sociodemographic information and history regarding diagnosis and/or treatments for OSA and neurocognitive disorders was collected from patients' charts. Medical information relative to comorbidities such as hypertension, diabetes mellitus, smoking, stroke history, hyperlipidemia, and coronary artery disease was also collected from patient charts. <h3>Results</h3> A total of 84 participants, aged 51 to 97, were recruited from June 2019 to November 2021. Of the patients recruited, 21 were cognitively intact with a mean age of 71.3 years, BMI of 35.2 kg/m², and STOP-BANG score of 4.5; 42 had mild cognitive impairment with a mean age of 75.9 years, BMI of 29.8 kg/m², and STOP-BANG score of 3.7; 21 had major neurocognitive disorder (dementia) with a mean age of 82.7, BMI of 27.0 kg/m², and STOP-BANG score of 3.9. We found that the association between preserved cognitive functions, as measured by the SLUMS and lower risk of OSA as measured by the STOP-BANG was not statistically significant (p=.104 per Chi-Square testing). When the data was further stratified, patients with preserved cognition were younger in age and found to have statistically significant higher BMI (p<0.05) as well as higher STOP-BANG scores (p<0.05). Further, patients with normal cognition had a higher prevalence of diabetes, coronary artery disease, hyperlipidemia, and smoking when compared to cognitively impaired patients. <h3>Conclusions</h3> Given that older age is a risk factor for cognitive decline, patients in our study with normal cognition were notably younger in age; however, they were found to have more medical comorbidities. These patients also had higher BMI scores and a higher neck circumference which correlates with a higher risk for OSA. Conversely, patients with lower SLUMS scores were older, had lower risk for OSA, and had fewer medical comorbidities, including lower BMI and lower neck circumference. In conclusion, younger patients with normal cognition may be in nursing homes due to their multiple, severe medical comorbidities. As previously stated, more medical comorbidities confer a higher risk for OSA. Overall, small sample size and the diagnostic precision of the SLUMS exam are limitations of this study. Future directions would include further studies with larger sample sizes to evaluate the interplay of medical comorbidities in developing OSA and subsequent cognitive decline, specifically within nursing homes.