Title: Unraveling the Complexity: Navigating the Literature Review on Cognitive Evoked Potentials

in Obstructive Sleep Apnea Syndrome

Delving into the intricacies of cognitive evoked potentials in obstructive sleep apnea syndrome
(OSAS) can be a daunting task. As researchers and scholars endeavor to grasp the nuances of this
field, they often find themselves confronted with a vast and sometimes overwhelming body of
literature. The exploration of cognitive evoked potentials in OSAS necessitates a meticulous review
of studies, theories, methodologies, and findings, all of which contribute to a deeper understanding
of this multifaceted condition.

The process of writing a literature review on cognitive evoked potentials in OSAS demands not only
a comprehensive understanding of the subject matter but also adept research skills and critical
analysis. It involves sifting through countless research articles, journals, and academic papers to
identify relevant information, discern patterns, and synthesize findings. Moreover, it requires the
ability to evaluate the quality and reliability of sources, as well as to contextualize findings within
the broader scope of existing knowledge.

One of the greatest challenges in writing a literature review on this topic lies in the complexity and
interdisciplinary nature of OSAS itself. OSAS encompasses various physiological, neurological, and
psychological factors, all of which intersect and influence cognitive processes. Consequently,
literature on cognitive evoked potentials in OSAS often spans multiple disciplines, including sleep
medicine, neurology, psychology, and cognitive science, further complicating the review process.

Furthermore, the dynamic nature of research in this field means that new studies and findings are
continually emerging, adding to the already extensive body of literature. Staying abreast of the latest
developments and incorporating them into a literature review requires diligence and ongoing effort.

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literature reviews that contribute to advancing our understanding of this complex phenomenon.
Conversely, decreased snoring reports could be secondary to a lower frequency of having a bed
partner or hearing deficits in the elderly. In contrast to metabolic acidosis, hypocapnic hypoxia
decreases the PaCO 2 -AT difference. Cheyne-Stokes breathing—central sleep apnea Associated
with congestive heart failure Associated with neurologic disease 3. The occurrence of sleep-
disordered breathing among middle-aged adults. For this reason, the term CompSA is sometimes
applied. Patients who snore or have central apnea mainly in the supine position might be assumed to
be the best candidates for CPAP treatment. Another group of patients required either nasal bilevel
pressure-support ventilation or mechanical ventilation with or without oxygen. First, the scoring of
hypopnea based on airflow and desaturation has good intra-and interscoring reliability, whereas the
scoring of arousals does not ( 26, 27 ). The lung volume dependence may be greater in patients with
OSAHS ( 72 ). They generally present with a narrowing of the airway related to intermittent
hypercarbia and hypoxia. Relationship between obstructive sleep apnea severity and brain activation
during a sustained attention task. The term obstructive sleep apnea hypopnea syndrome (OSAHS)
has been used to be more inclusive. T WAQ (9) where the matrix Q has been computed in the
previous whitening or orthogonalization step. There is also a reduction in flow by nasal pressure with
a flattening in the inspiratory shape. FIGURE 18-4 Obstructive hypopnea with arousal at event
termination. Infants and children normally have a narrower airway than adults. The moving time
average MTA-EMGgg of the genioglossus EMG (EMGgg) was measured using a mouthpiece
electrode. This includes loss of fluid reasoning, shifting, and inhibition. Effect sizes for sleepiness
impairment in patient samples with severe OSAHS are large for objective tests (?1.5 SD) and larger
still (?2.5 SD) for subjective ratings. However, there has been considerable controversy about the
definition of hypopnea and the frequency of events that is considered abnormal. Stradling and
coworkers 20 found alcohol consumption to be associated with the presence of OSA in a group of
middle-aged men. Then Fisher transform was used to transform the correlation coefficient into z-
score graph to improve the normality. The patterns of ventilation in treatment-emergent CSA
(nonhypercapnic, non-CSB CompSA) resembles that of ICSA. The presence or absence of arousal
was not considered. Many patients with OSAHS have a much higher AHI during REM sleep or have
events only during REM (REM-related OSAHS). The percentage of total respiratory events that
must be central is not well defined but is usually taken as greater than 50%. Recall the equation
introduced in (3), the source sig- nals s are assumed to be mutually uncorrelated and tem- porally
correlated (instead of independents) in a second order statistic framework. Most outcomes in a
computer administered driving based task were significantly improved in one trial of CPAP, 29 with
small to moderate improvements of 0.5 SD or less against the large and very large improvements
observed in sleepiness. Prilipko et al. showed that functional inactivation of the DMN region in OSA
patients was significantly related to behavioral performance and episodic memory compared with the
healthy group ( 49 ). In older case series of patients with severe OSAHS, over three quarters reported
difficulties at work and reduction in work capacity and efficiency. 35 Even in more recent samples
the prevalence of such perceived problems remains high, with approximately two thirds of new
patients still reporting difficulties in work efficiency and performing new tasks. 36 In a disease
specific symptom inventory, 43 two thirds experienced memory disturbance and three quarters
problems with concentration.
Aberrant topographical organization of the default mode network underlying the cognitive
impairment of remitted late-onset depression. In 1956, Burwell and coworkers 1 used the term
pickwickian syndrome to describe individuals with obesity, hypersomnolence, hypercapnia, cor
pulmonale, and erythrocytosis. They are often assumed to simply have COPD and are treated with
nocturnal oxygen alone. Pathophysiology of Idiopathic CSA As reflected in the term “idiopathic,”
the etiology of primary CSA is unknown. When placed on continuous positive airway pressure
(CPAP), the underlying ventilatory instability was uncovered. This classification is not entirely
satisfactory because patients with OHS have various combinations of OSA, abnormal ventilatory
control, and respiratory pump abnormality (mass loading due to obesity). FIGURE 18-9 This tracing
shows the fall in integrated genioglossus EMG activity and tidal volume during a burst of eye
movements during REM sleep in a normal individual. Memory and obstructive sleep apnea: a meta-
analysis. Sleep fragmentation reduces hippocampal CA1 pyramidal cell excitability and response to
adenosine. Relationship between obstructive sleep apnea severity and brain activation during a
sustained attention task. Illness-specific scales assessing the impact of OSAHS have also been
developed, including the Calgary sleep apnoea quality of life index (SAQLI) 43 and the functional
outcomes of sleepiness questionnaire (FOSQ). 44 For the FOSQ subscales, large impairment effect
sizes of ?1 SD are found in patients with OSAHS, 44 as might be expected of an instrument
designed to investigate specific symptoms of sleepiness. As periods of REM sleep are longest and
the REM density (number of eye movements per time) is the highest during the early morning hours,
it is not surprising that this is the time of the greatest changes in ventilation during sleep.
Computation on this model can be difficult as the presence of noise will influence the correlation
between signals. Memory before and after sleep in patients with moderate obstructive sleep apnea.
Saturation of pulse oxygen (SpO 2 ), sleep latency, total sleep time, sleep efficiency, sleep stage,
awakening, and respiratory events were recorded ( 26 ). Obesity Hypoventilation Syndrome Most
patients with the OSAHS do not have daytime hypoventilation. To select the appropriate ICA
algorithms for separat- ing the EEG signals, three types of tests have been car- ried out. 1) The five
simulated EEG signals ( Figure 1 ) were processed directly without add itio n al noise to the mixtur
e. As discussed in Chapter 8, the definition of hypopnea has varied considerably. 7, 8 The American
Academy of Sleep Medicine (AASM) scoring manual 9 recommends scoring apnea on the basis of
an oronasal thermal sensor and hypopnea on the basis of nasal pressure monitoring. A 10% weight
loss predicted a 26% reduction in the AHI. In Figure 18-3, a fall in genioglossus activity as the
patient returns to sleep is associated with an obstructive apnea. By using the vector-matrix notation,
the above mixing model is writ- ten as. Chang Xi et al. used whole-brain voxel level DC combined
with machine learning to distinguish major depression and bipolar disorder. The diagnosis of a CSA
syndrome requires that the majority of apneic events be central in nature. Ip and coworkers 35 found
a similar prevalence of OSA in a Chinese population as in whites. The Creative Commons Public
Domain Dedication waiver ( ) applies to the data made available in this article, unless otherwise
stated. Of note, patients with the OSAHS will have variable proportions of obstructive apneas and
hypopneas. Schematic explanations for the mechanical model of the pharyngeal airway. Ancoli-Israel
and colleagues 28 studied 427 community-dwelling elderly age 65 years or older using limited
channel ambulatory monitoring. Conversely, decreased snoring reports could be secondary to a lower
frequency of having a bed partner or hearing deficits in the elderly. Clinical practice guideline for
diagnostic testing for adult obstructive sleep Apnea: an American academy of sleep medicine clinical
practice guideline.
We describe a computer model based on patient-specific anatomy of obstructive sleep apnea (OSA)
subjects wherein the percentage and sites of upper airway collapse are compared to findings on
drug-induced sleep endoscopy (DISE). Furthermore, OSA has been shown to be associated with
mild cognitive impairment (MCI), especially in older adults ( 4 ). The use, distribution or
reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s)
are credited and that the original publication in this journal is cited, in accordance with accepted
academic practice. The esophageal pressure swings increase toward the end of the event, consistent
with a progressive increase in inspiratory effort. Patients with CompSA without an obvious etiology
(no narcotics or heart failure) are termed idiopathic CompSA for lack of a better terminology. CHF,
neurologic disorders, or medications suppressing ventilation are not present. Periods of diminished
diaphragmatic activity (reflected in decreased esophageal pressure excursions) and tidal volume
associated with the phasic changes of REM sleep (associated with bursts of eye movements). Upper-
airway reflexes triggered by negative pressure also help maintain upper-airway patency during
wakefulness. The identification of micro-awakenings in adults is based on ECG interpretation. All
nerve measurements were compared with reference values, as well as between the untreated patients
with obstructive sleep apnea and control subjects. From Skatrud JB, Dempsey JA: Interaction of
sleep state and chemical stimuli in sustaining rhythmic ventilation. Continuous positive airway
pressure improves sleepiness but not calculated vascular risk in patients with minimally symptomatic
obstructive sleep apnoea: the MOSAIC randomised controlled trial. Foam pads were used to reduce
the patient's head movement, and earplugs were used to reduce scanner noise. Excessive daytime
sleepiness is a burden for the majority of patients. For a random noisy vector x ( k ), the mixing ICA
model can be represented as. ICA technique not only able to separate the brain activities from non-
brain ac- tivities, it is also used to study the brain activities by an EEG analyst in order to determine
the brain disorders. Association of sleep-disordered breathing and the occurrence of stroke. In
contrast, in children more variables have to be considered, as most micro-awakenings are subcortical
and are not necessarily observable through ECG. The loss of accessory inspiratory muscles can
compromise the ability to maintain adequate ventilation, especially in patients with muscle weakness
or a high work of breathing. The variance of the model can be effectively reduced by constructing
the training set with random sampling so that each feature is a part of the whole feature vector. The
reduction in airflow is associated with a 4% arterial oxygen desaturation and would therefore meet
the hypopnea ciriteria based on oxygen desaturation. Of note, one case report found that CPAP
helped but bilevel positive airway pressure (BPAP) worsened CSA. 33 BPAP may destabilize the
system by augmenting ventilation. Cognition and daytime functioning in sleep-related breathing
disorders. Dynamic imaging of the upper airway during wakefulness shows the smallest diameter at
end expiration. The purpose of the ICA is to formulate a linear trans- formation W of the dependent
sensor signals x that mak e the output as indep endent as possible. As will be discussed later, the AHI
value for a given patient can vary tremendously depending on the definition of hypopnea and the
technology used to monitor airflow ( 8, 9 ). In mixed hypopnea, there is a fall in respiratory effort but
the fall in flow is proportionately greater and there is evidence of airflow limitation. In 1956, Burwell
( 1 ) used the term Pickwickian syndrome to describe individuals with obesity, hypersomnolence,
hypercapnia, cor pulmonale, and erythrocytosis. In the last 20 years, different types of algorithms
were proposed and most of the algorithms proposed that the sources are stationary and are based
implicitly on high order statistic (HOS) algorithms. With the application of HOS algorithms,
Gaussian sources cannot be separated as they do not have higher than two statistic moments while
the second order statistic do not have such con- straint. Comparison of noiseless and noise (20 dB)
histogram for S.
A combined neuropsychological and brain imaging study of obstructive sleep apnea. The evidence is
compatible with hypotheses that these deficits are reversible with treatment, although with larger
improvements in subjective than objective tests and a broader range of enhancements for patients
with more severe disease. Finally, non-zero coefficient features were selected to train the
classification model. Schematic explanations for the mechanical model of the pharyngeal airway.
Internal structures of the globus pallidus in patients with Parkinson's disease: evaluation with phase
difference-enhanced imaging. First, the scoring of hypopnea based on airflow and desaturation has
good intra-and interscoring reliability, whereas the scoring of arousals does not ( 26, 27 ). Cognitive
executive dysfunction in patients with obstructive sleep apnea syndrome (OSAS) after CPAP
treatment. Central apnea in these patients is much less common during stage N3 and REM sleep. A
10% increase in weight was associated with a sixfold increase in the risk of developing moderate to
severe OSA. The initial portion (C) is a central apnea characterized by absent ventilatory effort.
Morrell and coworkers ( 76 ) demonstrated a progressive fall in end-expiratory retropalatal cross-
sectional area as well as end-expiratory lung volume in the breaths leading up to obstructive apnea.
Acetazolamide induces a metabolic acidosis and reduces the pH even if the PaCO 2 also decreases
slightly. This variance with clinical experience could be due to either the nonhomogeneous nature of
REM or the fact that drops in diaphragm activity are also important for inducing apnea and
hypopnea. In summary, a reduction in airflow (nasal pressure) with flattening that is followed by an
arousal, but less than a 4% arterial oxygen desaturation, could be classified as either a hypopnea or a
flow-limitation RERA, depending on the definition of hypopnea that is used. Later in the disease
course, these may present with hypercapnic respiratory failure and cor pulmonale. We now know that
Pickwickian patients represent the “tip of the iceberg” of the larger group of patients with sleep-
disordered breathing (SDB). As discussed in this chapter, many patients develop central apnea as a
result of the use of potent narcotics. All participants received an overnight PSG (from 10 p.m. to 6
a.m.), using the Respironics LE physiological monitoring system of (Alice 5 LE, Respironics,
Orlando, FL, USA). Resting-state functional connectivity abnormalities in patients with obsessive-
compulsive disorder and their healthy first-degree relatives. Currently, the research on OSA and
MCI is still in its infancy; however, there is some evidence suggesting that oxidative stress and
endothelial function damage caused by intermittent hypoxia are related to cognitive impairment ( 5
). A head-to-head comparison study between CPAP and an oral appliance (mandibular advancement
device). Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for
obstructive sleep apnoea: a randomised prospective parallel trial. However, discussion of patients
with central apnea and hypoventilation syndromes together is useful clinically because they have
many similar aspects of pathophysiology and treatment. This could improve the reliability when
providing self-ratings in a stimulating laboratory or clinic environment where sleepiness might be
reduced by situational factors. Pathogenesis of Upper-airway Obstruction A detailed discussion of
the pathogenesis of upper-airway obstruction is beyond the scope of this chapter. The latency from
lights out to sleep onset is the principal outcome measure. However, definite epidemiologic evidence
for a worsening of OSA with chronic alcohol consumptions is lacking. Primary sleep apnea of infancy
From American Academy of Sleep Medicine: ICSD-2 International Classification of Sleep Disorders,
2nd ed. There are a few algorithms have been proposed in the past years and the most well known
algorithm is known as Donoho’s universal thresholding. The denoising results were magni- fied with
the purpose of evaluating the robustness of the Figure 10.
We aimed to use computational fluid dynamics (CFD) in conjunction with patient upper airway
scans to understand the upper airway response to treatment. Relationship between obstructive sleep
apnea severity and brain activation during a sustained attention task. Effects of levodopa therapy on
voxel-based degree centrality in Parkinson's disease. The CSA-CSB patients also had a longer delay
in the arterial oxygen saturation (SaO 2 ) nadir. Keywords: Continuous positive airway pressure,
Neurocognitive, Obstructive sleep apnea. From the plotted graph of IS avg versus ICA algorithms in
the presence of noise (Gaussian or Uniform), the robust SOBI (SOBI-RO) algorithm appears to be a
better algo- rithm in separating the simulated EEG signals. 3) Finally, Monte Carlo Analysis is used
to evaluate the selected ICA algorithms in order to verify the ro- bustness of the robust-SOBI
(SOBI-RO) algorithm. The esophageal pressure shows a progressive increase in negative pressure
followed by an arousal and reduction in the pressure swings. As noted previously, the sleeping PaCO
2 is normally about 2 to 8 mm Hg above waking value. Foam pads were used to reduce the patient's
head movement, and earplugs were used to reduce scanner noise. Neuropsychological function in
mild sleep-disordered breathing. Postmenopausal Status Conventional wisdom is that
postmenopausal women have a greater incidence of OSA than premenopausal women. It seems
likely that consumption of alcohol (or abstinence from alcohol) could significantly change the AHI
in individual patients. During the apnoic event, vagal stimulation to the heart increases, leading to
bradycardia (immersion reflex). Disrupted functional brain network organization in patients with
obstructive sleep apnea. Overall, in OSA it is possible to consider a conceptual model based on
repeated acute insults (i.e. continuous hemodynamic, hypoxemic and autonomic variations) that lead,
over time, to a structural and electrical cardiac remodeling capable of constituting a potentially
arrhythmogenic substrate (Figure 1). To add to the confusion, some publications and sleep centers
use the term RDI as the number of apneas and hypopneas per hour of sleep. As the y i is the
estimation of s j, the ideal nor- malized vector g i is the unit vector of T i w ? ? 0 010 j U. U c (8)
With the formation of Q matrix, the whitened signal z. In classical OSAHS, changes to cognitive
performance scores after treatment are smaller in size and sparser in appearance than those for
sleepiness. The lack of obesity in Asian patients should certainly not discourage evaluation for
possible sleep apnea. DeBacker and associates 27 studied the effects of acetazolamide 250 mg 1
hour before sleep after 1 month of treatment in ICSA patients. The alternative definition of
hypopnea requires a 50% or greater reduction in the nasal pressure signal associated with either an
arousal or a 3% or greater arterial oxygen desaturation. The hypercapnic CSA group can be divided
into a “won’t breathe” group (can reduce their PaCO 2 with voluntary increases in ventilation) and a
“can’t breathe” group due to an abnormal thoracic cage or neuromuscular weakness. Comparison of
therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep
apnoea: a randomised prospective parallel trial. Note that there was some variability with one trial
resulting in a P ET CO 2 of 38 mm Hg that did not result in central apnea. Conversely, decreased
snoring reports could be secondary to a lower frequency of having a bed partner or hearing deficits
in the elderly. It was hypothesized that patients with obstructive sleep apnea would have bilaterally
significantly impaired amplitudes of both motor and sensory peripheral nerve-evoked potentials of
both lower and upper limbs. The loss of accessory inspiratory muscles can compromise the ability to
maintain adequate ventilation, especially in patients with muscle weakness or a high work of
breathing. Although they have some success, they are neither satisfactorily sensitive nor specific
enough to be a substitute for objective documentation of the presence of OSA by a sleep study. Of
note, early in the disease course, some patients with chronic hypoventilation syndromes will have an
increased PaCO 2 only during sleep.
The 88% occurs before the termination of the event pictured. CHF, neurologic disorders, or
medications suppressing ventilation are not present. Results revealed 40% of the patients reported
positive sleep complaints mostly in the form of muscle cramps, numbness and tingling sensations in
lower limbs and leg restlessness. In normal persons, during REM sleep, genioglossus tonic activity is
reduced but phasic activity can still be detected if intramuscular electromyography (EMG) electrodes
are used ( Fig. 18-9 ). During bursts of eye movements, both diaphragmatic and genioglossus phasic
activity is often decreased ( 81 ). Whether treating sleep apnoea can fully reverse its chronic
consequences remains to be established in adequately designed studies. Patients with these
syndromes have a normal or low PaCO 2 during wakefulness. Multiple naps and the evaluation of
daytime sleepiness in patients with upper airway sleep apnea. Hypopnea Controversy It is not
possible to discuss the hypopnea controversy without briefly discussing the methods of airflow
monitoring. Excessive daytime sleepiness is a burden for the majority of patients. The random vector
of x is denoted by the mixtures 1,, n x x. Obstructive sleep apnea syndrome is associated with
deficits in verbal but not visual memory. Changes in upper-airway muscle activation and ventilation
during phasic REM sleep in normal men. Patients with CompSA without an obvious etiology (no
narcotics or heart failure) are termed idiopathic CompSA for lack of a better terminology. Whereas
the recent AASM scoring manual defines RERAs, the manual does not define the term RDI.
Thirteen of ICA algorithms were tested under no noise condition and the results are shown in Table
1. For example, suppose the spontaneous sleeping PaCO 2 is 42 mm Hg, then trials could
progressively induce PaCO 2 values of 41, 40, 39, 38, 37, and so on. From American Academy of
Sleep Medicine: ICSD-2 International Classification of Sleep Disorders, 2nd ed. Brain activation
changes before and after PAP treatment in obstructive sleep apnea. The HF component reflects the
activity of the parasympathetic nervous system, while the LF component is generally associated with
sympathetic activity. Many patients with OSAHS have a much higher AHI during REM sleep or
have events only during REM (REM-related OSAHS). Before the scan, all participants were
required to close their eyes, stay awake and not engage in specific thinking activities. Instead of
using the histogram of SIR for S (source), histogram of SIR for A (mixing matrix), shown in Figure
10, give reliable measurement especially in the presence of additional noise in the signal. The large
overlap between the initial brain damage and the extent of recovery after treatment suggests partial
recovery of non-permanent structural damage. The reason hypothyroidism exacerbates OSA is
unclear and possibly multifactorial. Children with this symptom have inspiratory aphasic activity in
the muscles of the upper tract of the airway during sleep. The goal of this study is to test the
hypothesis that the cure of obstructive sleep apnea syndrome by maxillomandibular advancement
surgery can be predicted by analyzing the effect of anatomical airway changes on the pressure effort
required for normal breathing using a high-fidelity, 3-D numerical model. Obstructive sleep apnea
syndrome: pathogenesis of neuropsychological deficits. Note that the decrease in airflow by nasal
pressure is greater than by thermistor (thermal flow). Morrell and coworkers ( 76 ) demonstrated a
progressive fall in end-expiratory retropalatal cross-sectional area as well as end-expiratory lung
volume in the breaths leading up to obstructive apnea. Neurocognitive Decline in Obstructive Sleep
Apnea: An Ignored Entity.