Sleep disorders and attention: a systematic review

RODRIGUES, Thiago; SHIGAEFF, Nadia

doi:10.1590/0004-282X-ANP-2021-0182

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View and Review • Arq. Neuro-Psiquiatr. 80 (5) • May 2022 • https://doi.org/10.1590/0004-282X-ANP-2021-0182 copy

Sleep disorders and attention: a systematic review

Distúrbios de sono e atenção: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background: Sleep is a special physiological state that occurs cyclically. The probable role of sleep in our organic functions remains to be explored to clarify the impact of sleep on brain functions. Sleep deprivation is known to affect all parts of the brain separately and independently, but further research is needed on the impact of sleep disorders on attention, particularly the specific types of attention that are most affected, and whether there is such a correlation. Objective: To conduct a systematic review of the possible correlation between sleep disorders and attentional performance. Methods: A systematic review and search at PubMed, SciELO, and Cochrane scientific databases for articles published in the last 10 years was carried out using the following keywords: sleep, attention, and attentional performance. Inclusion criteria were the use of attention tests and sleep disorders. Of the 1398 articles found, 15 were selected and included in this review. Results: The number of publications evaluating sleep and sleep disorders has increased, but is still limited. Of all the functions normally assessed, patients with sleep disorders perform worse on attention tasks, especially with sustained attention. However, these data require further investigation due to the complexity and diversity of the disorders, the small sample size of the included studies, and the fact that few studies used standardized tests. Conclusions: Our findings indicate that the correlation between sleep and attention is strong but limited. Few studies are devoted exclusively to the extent to which sleep disorders interferes with attention.

Keywords:
Sleep; Sleep Wake Disorders; Attention

Study	Sample	Sleep disorder	Tests used	Main findings	Main limitations
Bawden et al.¹⁷17. Castronovo V, Scifo P, Castellano A, Aloia MS, Iadanza A, Marelli S, et al. White matter integrity in obstructive sleep apnea before and after treatment. Sleep. 2014 Sep;37(9):1465-75. https://doi.org/10.5665/sleep.3994 https://doi.org/https://doi.org/10.5665/...	17 patients with polysomnographically diagnosed OSA in brief cognitive tests compared to 20 healthy controls (n=37)	OSA	MMSE, BCSB, DSS, ESS	OSA patients performed significantly worse than controls in the MMSE, in memory items from the BCSB, and in DS	Small sample
Waggoner et al.¹²12. Waggoner LB, Grant DA, Van Dongen HPA, Belenky G, Vila B. A combined field and laboratory design for assessing the impact of night shift work on police officer operational performance. Sleep. 2012 Nov;35(11):1575-7. https://doi.org/10.5665/sleep.2214 https://doi.org/https://doi.org/10.5665/...	27 male and 2 female police officers (n=29)	Sleep deprivation	KSS, PVT, PSQI, ESS, MAPS	Significant lower scores on attention tests and psychomotor vigilance	Small sample, sleep disorder was self-reported
Moraes et al.¹⁹19. Luz GP, Guimarães TM, Weaver TE, Nery LE, E Silva LO, Badke L, et al. Impaired sustained attention and lapses are present in patients with mild obstructive sleep apnea. Sleep Breath. 2016 May;20(2):681-7. https://doi.org/10.1007/s11325-015-1279-7 https://doi.org/https://doi.org/10.1007/...	38 participants divided into the following groups: Narcoleptic group (13 females; 6 males, mean age=37.58); control group (15 Female; 4 Male, mean age=34.42)	Narcolepsy	ESS-BR, VST, TMT	Narcoleptic patients showed higher degrees of EDS, an impaired executive attention at a temporal level and lower performance in working memory	Small sample
Karimi et al.¹⁶16. Karimi M, Eder DN, Eskandari D, Zou D, Hedner JA, Grote L. Impaired vigilance and increased accident rate in public transport operators is associated with sleep disorders. Accid Anal Prev. 2013 Mar;51:208-14. https://doi.org/10.1016/j.aap.2012.11.014 https://doi.org/https://doi.org/10.1016/...	72 males, 29 female drivers (n=101)	Hypersomnolence, insomnia, restless legs syndrome, OSA	ESS, KSS, FIS, ISI, IRLSS, Polysomnography, ANT, CTT, MWT	High prevalence of sleep disorders correlated with ANT poor results, improvement after OSA treatment	Few attention and cognitive tasks
Niu et al.¹³13. Niu S-F, Chu H, Chen C-H, Chung M-H, Chang Y-S, Liao Y-M, et al. A comparison of the effects of fixed- and rotating-shift schedules on nursing staff attention levels: a randomized trial. Biol Res Nurs. 2013 Oct;15(4):443-50. https://doi.org/10.1177/1099800412445907 https://doi.org/https://doi.org/10.1177/...	62 nurses in a medical center in Taiwan and classified in two groups: fixed-day-shift group (control group, n=30) and rotating-shift group (experimental group, n=32)	Sleep deprivation	CPSQI, D2	Significant less selective attention, performance speed and accuracy on the attentional test were poorer in nurses working night shift than in those working day shift	Only woman participated, sleep deprivation was induced
Oliveira et al.¹⁰10. Oliveira B de, De Martino MMF. Análise das funções cognitivas e sono na equipe de enfermagem nos turnos diurno e noturno. Rev Gaúcha Enferm. 2013 Mar;34(1):30-6. https://doi.org/10.1590/S1983-14472013000100004 https://doi.org/https://doi.org/10.1590/...	Nursing staff in a hospital in Minas Gerais (n=102)	Sleep deprivation	DSS	Subjects in this study with nocturnal shift have impaired results in attention tests, and self-report less quality of sleep overall. Important to point out that these individuals also have greater total sleep hours in comparison.	No sleep tests, even self-reported scales. The correlation is uncertain and the sample is small.
Castronovo et al.²⁴24. Alikhani M, Ebrahimi A, Farnia V, Khazaie H, Radmehr F, Mohamadi E, et al. Effects of treatment of sleep disorders on sleep, psychological and cognitive functioning and biomarkers in individuals with HIV/AIDS and under methadone maintenance therapy. J Psychiatr Res. 2020 Nov;130:260-72. https://doi.org/10.1016/j.jpsychires.2020.07.043 https://doi.org/https://doi.org/10.1016/...	17 patients with OSA and 15 controls (n=32)	OSA	MMSE, TMT, Stroop, ESS, PSQI	OSA patients showed impairments in most cognitive areas. After treatment, patients showed a significant improvement in sleepiness and in all cognitive tests, except for total time on Stroop test and Trial Making Test B	Small sample
Fortier-Brochu et al.²⁶26. Fortier-Brochu E, Morin CM. Cognitive impairment in individuals with insomnia: clinical significance and correlates. Sleep. 2014 Nov;37(11):1787-98. https://doi.org/10.5665/sleep.4172 https://doi.org/https://doi.org/10.5665/...	25 adults with primary insomnia and 16 controls (n=25)	Insomnia	Polysomnographic recordings, spectral analysis of the electroencephalogram, ISI, PASAT, CPT-II	Individuals with insomnia had poorer overall performance compared to participants of the control group and committed more errors in attention and episodic memory tasks. Significant cognitive impairments were more frequent with insomnia.	Small Sample
Djonlagic et al.¹⁴14. Djonlagic I, Guo M, Matteis P, Carusona A, Stickgold R, Malhotra A. First night of CPAP: impact on memory consolidation attention and subjective experience. Sleep Med. 2015 Jun;16(6):697-702. https://doi.org/10.1016/j.sleep.2015.01.017 https://doi.org/https://doi.org/10.1016/...	15 healthy controls and 29 patients with obstructive sleep apnea (n=44)	OSA	Polysomnography, PVT	Instant improvement in attention and vigilance based on PVT results	Small sample
Li et al.¹¹11. Li X, Zhou Z, Jia S, Hou C, Zheng W, Rong P, et al. Cognitive study on Chinese patients with idiopathic REM sleep behavior disorder. J Neurol Sci. 2016 Jul;366:82-86. https://doi.org/10.1016/j.jns.2016.04.047 https://doi.org/https://doi.org/10.1016/...	23 iRBD patients and 23 controls (n=46)	Idiopathic REM sleep behavior disorder (iRBD)	Polysomnography, MMSE, SCW, TMT, DSS	Negative correlation with the Trail Making B test, episodic verbal memory and non-verbal learning are the most affected domains in iRBD	Small sample
Luz et al.¹⁸18. Bawden FC, Oliveira CA, Caramelli P. Impact of obstructive sleep apnea on cognitive performance. Arq Neuro-Psiquiatr. 2011 Aug;69(4):585-9. https://doi.org/10.1590/S0004-282X2011000500003 https://doi.org/https://doi.org/10.1590/...	Thirty-nine mild OSA patients and 25 controls were included (n=64)	OSA	Polysomnography, FOSQ, PVT	There was a statistically significant difference between groups when comparing the “number of lapses” in PVT	Small sample, pilot study
Lancee et al.²⁰20. Moraes M, Rossini S, Reimão R. Executive attention and working memory in narcoleptic outpatients. Arq Neuro-Psiquiatr. 2012 May;70(5):335-40. https://doi.org/10.1590/s0004-282x2012005000007 https://doi.org/https://doi.org/10.1590/...	Participants with insomnia were divided in two groups: training group (n=67, 49 female and 18 male) and placebo training group (n=70, 51 female and 19 male).	Insomnia	ISI, DT, PSQI	Scores of attentional biases didn’t change at all, the control group showed the same results as the main group, and the study wasn’t able to tell the difference	Online application of DT could be a central factor in the results, conclusion doesn’t show if the attention bias can be altered through this method
Zhao et al.²⁵25. Zhao F, Xu H, Hong Y, Zhao Y, Yan H, Ma Q, et al. Attention network function of insomniacs improved by manual acupuncture: evidence from Attention Network Task. World J Acupunct Moxibustion. 2019;29(2):91-6. https://doi.org/10.1016/j.wjam.2019.05.006. https://doi.org/https://doi.org/10.1016/...	28 male and 36 female patients diagnosed with insomnia in Shanghai (n=64)	Insomnia and Sleep Disturbance	PSQI, ANT	Scores of alerting efficiencies increased more, while scores of total reaction time decreased more in treatment group, insomnia was found to be associated with higher scores in the executive control variable of the ANT	Small sample
Richards et al.¹⁵15. Richards KC, Gooneratne N, Dicicco B, Hanlon A, Moelter S, Onen F, et al. CPAP adherence may slow 1-year cognitive decline in older adults with mild cognitive impairment and apnea. J Am Geriatr Soc. 2019 Mar;67(3):558-64. https://doi.org/10.1111/jgs.15758 https://doi.org/https://doi.org/10.1111/...	Older adults, aged 55-89 with Mild Cognitive Impairment and Obstructive Sleep Apnea, divided into two groups: who used CPAP (experimental group, n=29) and those who did not use CPAP (control group, n=25)	Mild cognitive impairment (MCI), OSA	Polysomnography, SCW, PVT, ESS	There were significant decreases in daytime sleepiness, and improvement in attention performance in the two measurements performed, from baseline to six months, and from baseline to one year in the group that adhered to CPAP use compared to the group that did not use CPAP.	Study structure found the groups may have been different on unidentified variables that may have affected the study outcomes, like color/race
Alikhani et al.²³23. Norton R. The effects of acute sleep deprivation on selective attention. Br J Psychol. 1970 May;61(2):157-61. https://doi.org/10.1111/j.2044-8295.1970.tb01233.x https://doi.org/https://doi.org/10.1111/...	46 males with HIV infection (n=46)	Sleep disturbances self-reported	PSQI, ISI, ESS, D2	Treating sleep disturbances over a period of six to 12 weeks had a positive impact on aspects of sleep disturbance, symptoms of depression and anxiety, and cognitive performance	Small sample

Study	Design	Sample (n)	Nation	Attention type	Intervention?
Bawden et al.¹⁷17. Castronovo V, Scifo P, Castellano A, Aloia MS, Iadanza A, Marelli S, et al. White matter integrity in obstructive sleep apnea before and after treatment. Sleep. 2014 Sep;37(9):1465-75. https://doi.org/10.5665/sleep.3994 https://doi.org/https://doi.org/10.5665/...	Experimental/Clinical Trial	37	Brazil	Sustained	Yes
Waggoner et al.¹²12. Waggoner LB, Grant DA, Van Dongen HPA, Belenky G, Vila B. A combined field and laboratory design for assessing the impact of night shift work on police officer operational performance. Sleep. 2012 Nov;35(11):1575-7. https://doi.org/10.5665/sleep.2214 https://doi.org/https://doi.org/10.5665/...	Experimental/Randomized Controlled Trial	29	USA	Sustained	No
Moraes et al.¹⁹19. Luz GP, Guimarães TM, Weaver TE, Nery LE, E Silva LO, Badke L, et al. Impaired sustained attention and lapses are present in patients with mild obstructive sleep apnea. Sleep Breath. 2016 May;20(2):681-7. https://doi.org/10.1007/s11325-015-1279-7 https://doi.org/https://doi.org/10.1007/...	Prospective case-control	19	Brazil	Selective	No
Karimi et al.¹⁶16. Karimi M, Eder DN, Eskandari D, Zou D, Hedner JA, Grote L. Impaired vigilance and increased accident rate in public transport operators is associated with sleep disorders. Accid Anal Prev. 2013 Mar;51:208-14. https://doi.org/10.1016/j.aap.2012.11.014 https://doi.org/https://doi.org/10.1016/...	Experimental/Clinical Trial	101	Sweden	Selective, Sustained	Yes
Niu et al.¹³13. Niu S-F, Chu H, Chen C-H, Chung M-H, Chang Y-S, Liao Y-M, et al. A comparison of the effects of fixed- and rotating-shift schedules on nursing staff attention levels: a randomized trial. Biol Res Nurs. 2013 Oct;15(4):443-50. https://doi.org/10.1177/1099800412445907 https://doi.org/https://doi.org/10.1177/...	Experimental/Randomized Controlled Trial	62	China	Sustained	Yes
Oliveira et al.¹⁰10. Oliveira B de, De Martino MMF. Análise das funções cognitivas e sono na equipe de enfermagem nos turnos diurno e noturno. Rev Gaúcha Enferm. 2013 Mar;34(1):30-6. https://doi.org/10.1590/S1983-14472013000100004 https://doi.org/https://doi.org/10.1590/...	Descriptive and observational	102	Brazil	Selective, “Complex Attention”	No
Castronovo et al.²⁴24. Alikhani M, Ebrahimi A, Farnia V, Khazaie H, Radmehr F, Mohamadi E, et al. Effects of treatment of sleep disorders on sleep, psychological and cognitive functioning and biomarkers in individuals with HIV/AIDS and under methadone maintenance therapy. J Psychiatr Res. 2020 Nov;130:260-72. https://doi.org/10.1016/j.jpsychires.2020.07.043 https://doi.org/https://doi.org/10.1016/...	Experimental/Clinical Trial	32	Italy	Selective, Sustained	Yes
Fortier-Brochu et al.²⁶26. Fortier-Brochu E, Morin CM. Cognitive impairment in individuals with insomnia: clinical significance and correlates. Sleep. 2014 Nov;37(11):1787-98. https://doi.org/10.5665/sleep.4172 https://doi.org/https://doi.org/10.5665/...	Prospective case-control	25	Canada	Sustained	No
Djonlagic et al.¹⁴14. Djonlagic I, Guo M, Matteis P, Carusona A, Stickgold R, Malhotra A. First night of CPAP: impact on memory consolidation attention and subjective experience. Sleep Med. 2015 Jun;16(6):697-702. https://doi.org/10.1016/j.sleep.2015.01.017 https://doi.org/https://doi.org/10.1016/...	Experimental/Controlled Clinical Trial	44	USA	Sustained	Yes
Li et al.¹¹11. Li X, Zhou Z, Jia S, Hou C, Zheng W, Rong P, et al. Cognitive study on Chinese patients with idiopathic REM sleep behavior disorder. J Neurol Sci. 2016 Jul;366:82-86. https://doi.org/10.1016/j.jns.2016.04.047 https://doi.org/https://doi.org/10.1016/...	Prospective case-control	46	China	Selective, Sustained	No
Luz et al.¹⁸18. Bawden FC, Oliveira CA, Caramelli P. Impact of obstructive sleep apnea on cognitive performance. Arq Neuro-Psiquiatr. 2011 Aug;69(4):585-9. https://doi.org/10.1590/S0004-282X2011000500003 https://doi.org/https://doi.org/10.1590/...	Prospective case-control	64	Brazil	Sustained	No
Lancee et al.²⁰20. Moraes M, Rossini S, Reimão R. Executive attention and working memory in narcoleptic outpatients. Arq Neuro-Psiquiatr. 2012 May;70(5):335-40. https://doi.org/10.1590/s0004-282x2012005000007 https://doi.org/https://doi.org/10.1590/...	Experimental/Randomized Controlled Trial	137	Netherlands	Selective	Yes
Zhao et al.²⁵25. Zhao F, Xu H, Hong Y, Zhao Y, Yan H, Ma Q, et al. Attention network function of insomniacs improved by manual acupuncture: evidence from Attention Network Task. World J Acupunct Moxibustion. 2019;29(2):91-6. https://doi.org/10.1016/j.wjam.2019.05.006. https://doi.org/https://doi.org/10.1016/...	Experimental/Randomized Controlled Trial	64	China	Selective, Sustained	Yes
Richards et al.¹⁵15. Richards KC, Gooneratne N, Dicicco B, Hanlon A, Moelter S, Onen F, et al. CPAP adherence may slow 1-year cognitive decline in older adults with mild cognitive impairment and apnea. J Am Geriatr Soc. 2019 Mar;67(3):558-64. https://doi.org/10.1111/jgs.15758 https://doi.org/https://doi.org/10.1111/...	Experimental/Clinical Trial	25	USA	Selective, Sustained	Yes
Alikhani et al.²³23. Norton R. The effects of acute sleep deprivation on selective attention. Br J Psychol. 1970 May;61(2):157-61. https://doi.org/10.1111/j.2044-8295.1970.tb01233.x https://doi.org/https://doi.org/10.1111/...	Experimental/Randomized Controlled Trial	46	Iran	Sustained	Yes

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[1] Correspondence: Nadia Shigaeff; Email: nadia.shigaeff@ufjf.edu.br.