Juvenile Arthritis with Sleep Apnea Impairs Neurobehavioral Performance

Children with juvenile idiopathic arthritis (JIA) and comorbid obstructive sleep apnea (OSA) had a higher obstructive apnea hypopnea index (OAHI) and more arousals than healthy controls and children with JIA without OSA, according to a study published online in The Journal of Rheumatology.¹

For the study, 68 children (age 6 to 11 years) with JIA recruited from Seattle Children’s Hospital rheumatology clinic and 67 healthy controls underwent overnight polysomnography, followed by a multiple sleep latency test (MSLT) and neurobehavioral performance assessments the next day.

Neurobehavioral performance was assessed via the Cambridge Neuropsychological Test Automated Battery (CANTAB); the assessment domains include (1) a motor screening test, which measures the participant’s speed of response and the accuracy of the participant’s pointing; (2) RTI, a measure of visual scanning and processing speed (simple and 5-choice); (3) match to sample visual search (MTS) tests, a measure of reaction and movement time; and (4) rapid visual processing (RVP), a measure of sustained attention, which is comprised of variables including the probability of hitting a target sequence and the probability of false alarm.

OAHI was defined as the number of obstructive apneas and hypopneas per hour of sleep. Based on the number of OAHI ≥1.5, 51% of children with JIA (n = 35) were identified as having OSA. In addition to significantly higher OAHI and arousals in JIA with OSA compared with JIA and controls without OSA, results showed statistically significant differences between patients for RVP probability of a hit and simple RTI groups. Patients in the JIA/OSA cohort performed more poorly in the probability to hit task than controls without OSA; however, scores did not significantly vary between JIA patients with and without OSA. Patients with JIA, both with and without OSA, had longer RTI than patients in the control group.

In an email interview with Rheumatology Advisor, lead investigator Theresa Ward, PhD, of the University of Washington School of Nursing, noted that the presence of OSA is a serious health concern that places children at increased risk for adverse health outcomes, increased use of healthcare resources, and poor clinical care management. To identify children with JIA who are at risk for OSA, Dr. Ward stated that primary care pediatricians and pediatric rheumatologists can use the 22-item Sleep-Related Breathing Disorder (SRBD) scale of the Pediatric Sleep Questionnaire, which assesses snoring frequency, loud snoring, observed apneas, difficulty breathing during sleep, daytime sleepiness, inattentive or hyperactive behavior, and other features associated with pediatric OSA. “Our prior research shows a high prevalence — 40%, 50% — of obstructive sleep apnea in school-age children with juvenile idiopathic arthritis, measured by polysomnography. Importantly, none of the juvenile idiopathic arthritis children with obstructive sleep apnea were screened for a sleep disorder, and none had been referred to a sleep clinic for an obstructive sleep apnea evaluation. Given the adverse health outcomes associated with that obstructive sleep apnea, its timely diagnosis and treatment is important.”

Summary and Clinical Applicability

“OSA was prevalent in JIA and may predispose children to daytime sleepiness and impaired neurobehavioral performance,” concluded the investigators. “Effective detection and treatment of OSA may reduce morbidity, decrease healthcare costs, and improve disease management.”

Study Limitations

• Polysomnography was performed on only 1 night and may not have represented typical sleep.
• Medications were included as a covariate in the regression analysis; however, because few children took the same medications, medication type was not subject to a refined analysis.
• Control and JIA groups were not matched for maternal education.

Reference

Ward TM, Beebe DW, Chen ML, et al. Sleep disturbances and neurobehavioral performance in juvenile idiopathic arthritis [published online January 15, 2017]. J Rheumatol. doi:10.3899/jrheum.160556

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