title: Effects of obstructive sleep apnea on sleep quality, cognition, and driving performance in patients with cirrhosis.
abstract: OBJECTIVE
  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 and prospective study of 118 subjects. Subjects were assigned to 1 of 4 groups: those with OSA and cirrhosis (without hepatic encephalopathy or ascites, n = 34), those with cirrhosis only (n = 30), those with OSA only (n = 29), and those without OSA or cirrhosis (controls, n = 25). None of the 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 indicated 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 with more than 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 OSA subjects with and without cirrhosis. After CPAP therapy, performance on the paper-pencil test improved significantly only in subjects with OSA without cirrhosis.
  
  
  CONCLUSIONS
  OSA should be considered in evaluating sleep impairment in patients with cirrhosis. In patients with cirrhosis and OSA, psychomotor speed and attention issues likely are related to cirrhosis, whereas executive function and simulator performance are affected by OSA. CPAP therapy improves executive function and simulator performance in patients with OSA, regardless of cirrhosis.
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia. Electronic address: jsbajaj@vcu.edu.
authors.forename: Jasmohan S
authors.initials: JS
authors.lastname: Bajaj
authors.affiliation: Department of Biostatistics, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Leroy R
authors.initials: LR
authors.lastname: Thacker
authors.affiliation: Division of Sleep Medicine, Department of Neurology, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: David
authors.initials: D
authors.lastname: Leszczyszyn
authors.affiliation: Division of Sleep Medicine, Department of Neurology, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Samuel A
authors.initials: SA
authors.lastname: Taylor
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Heuman
authors.affiliation: Division of Sleep Medicine, Department of Neurology, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Shekar
authors.initials: S
authors.lastname: Raman
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Richard K
authors.initials: RK
authors.lastname: Sterling
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Muhammad S
authors.initials: MS
authors.lastname: Siddiqui
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: R Todd
authors.initials: RT
authors.lastname: Stravitz
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Arun J
authors.initials: AJ
authors.lastname: Sanyal
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Puneet
authors.initials: P
authors.lastname: Puri
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Velimir
authors.initials: V
authors.lastname: Luketic
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Scott
authors.initials: S
authors.lastname: Matherly
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Michael
authors.initials: M
authors.lastname: Fuchs
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Melanie B
authors.initials: MB
authors.lastname: White
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Nicole A
authors.initials: NA
authors.lastname: Noble
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: Ariel B
authors.initials: AB
authors.lastname: Unser
authors.affiliation: Division of Clinical Psychology, Department of Psychiatry, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia.
authors.forename: James B
authors.initials: JB
authors.lastname: Wade
mesh_terms: D000328:Adult; D000368:Aged; D001334:Automobile Driving; D003071:Cognition; D045422:Continuous Positive Airway Pressure; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020181:Sleep Apnea, Obstructive / Q000150:complications* / Q000628:therapy; D012893:Sleep Wake Disorders
keywords: CPAP; Chronic Liver Disease; Covert Hepatic Encephalopathy; Minimal Hepatic Encephalopathy