2-year Decline On An SSRI With Undiagnosed OSA€¦ · 2-year Decline On An SSRI With Undiagnosed OSA Kevin P. O ... Neurocognitive impairment in obstructive sleep apnea, ... dysfunction

2-year Decline On An SSRI With Undiagnosed OSA

Kevin P. O’Brien, Ph.D., ABPPArizona Neuropsychology, [email protected] 24, 2017

Guide for Aviation Medical Examiners (2015)

Guide for Aviation Medical Examiners (2015)

Guide for Aviation Medical Examiners (2015)

Demographics & Medical Hx

Demographics:• Age: 29• Gender: Male• Handedness: Right• Education: 16• Certificate: 3rd Class initially; then 1st Class• Years Flying: 2+Medical History:• Pediatric osteoarthritis• Micro discectomy (age 25)• Pain in back, shoulders, knee; takes OTC prn

Psychiatric History

• Social Anxiety D/O (DSM-IV: 300.23)• Symptoms [Onset at age 16]:

• Marked dry mouth• Tingling hands• Sweating• Increased heart rate

• Initial Tx w/fluoxetine & resolution of sx’s in 6 months.

• Recurrence 4 years later; fluoxetine resumed x 2 years but switched to Lexapro later that year due to ASE’s.

• Due to break-thru anxiety sx’s; Lorazepam prn added which he took off and on up to 1.5 mg per day.

• Stopped Lorazepam & has only taken Lexapro since 2012.

Initial CogScreen-AE (March 2013)

Index # Scores <=5th

%ile Percentile T-Score

Speed 3 10 37Accuracy 1 52.5 51Thruput 4 5 34Process 1 35 46

Index # Scores <=15th

%ile Percentile T-Score

Speed 7 10 37Accuracy 3 35 46Thruput 6 10 37Process 1 72.5 56

LRPV = 0.3053

Taylor Aviation Factor Scores (March 2013)

Factor Description T-ScoreAttribute Identification Deductive reasoning 47.17

Motor Coordination Motor coordination under speed conditions 63.33

Visual Association Memory Visual learning and recall 54.51Speed/Working Memory

Visual scanning/perceptual speed/working memory 45.52

Tracking Visual/psychomotor tracking accuracy 62.71

Additional Npsy Testing

• CPT-2: • Slow HIT response time “suggesting inattention”• Normal omission and commission error rates

• PASAT: • Trial 1 & 2: Average for age & education

• Trailmaking Test:• A: Low average (16th %ile) [Age & education]• B: Low average (25th %ile) [Age & education

• WCST:• Categories: 6/6• Perseverative errors: WNL (55th %ile) / FTMS = 1 (WNL)

• Stroop:• Word: 5th %ile• Color: 5th %ile• Color-Word: 34th %ile [NB: Invalid score per manual]

Npsy #1 Impressions / FAA Action

• Initial NP made no specific statement made about whether or not pilot met CFR §67.309 or CFR §67.307. Pilot was subsequently cleared to fly by FAA.

Npsy Follow-up Per SSRI Protocol (March 2015)

• Pilot Report / Status:• Denies any physical, cognitive, or emotional Sx’s.

• Later, acknowledged occasional pain (3-4 / 10) relieved with OTC.

• Denies any stressors or sleep problems.• Medications: Lexapro only.• Alcohol: Occasional use.• Denies current or past recreational or illicit drug use.• Has accumulated >750 hours and working as CFI/CFII

Follow-up CogScreen-AE (March 2015)Scores from March 2013 evaluation in Red

Index # Scores <=5th %ile Percentile T-Score

Speed 8 [3] <2.5 [10] <30 [37]Accuracy 2 [1] 20 [52.5] 42 [51]Thruput 7 [4] <2.5 [ 5 ] <30 [34]Process 2 [1] 10 [35] 37 [46]

Index # Scores <=15th %ile Percentile T-Score

Speed 8 [7] 7.5 [10] 35 [37]Accuracy 4 [3] 20 [35] 42 [46]Thruput 9 [6] 2.5 [10] 30 [37]Process 3 [1] 20 [72.5] 42 [56]

Current LRPV = 0.9753 Prior LRPV = 0.3053

Taylor Aviation Factor Scores (March 2015)Scores from March 2013 evaluation in Red

Factor Description T-ScoreAttribute Identification Deductive reasoning 13.16 [47.17]

Motor Coordination Motor coordination under speed conditions 63.33 [63.33]

Visual Association Memory Visual learning and recall 48.67 [54.51]

Speed/Working Memory

Visual scanning/perceptual speed/working memory

47.89 [45.52]

Tracking Visual/psychomotor tracking accuracy 63.99 [62.71]

Discussion with AME

• Initial Npsy evaluation findings reviewed with AME.

• AME agrees with plan for additional testing.

• AME indicated he would call pilot and recommend that he self-limit flying activities until further testing completed.

• When seen 2 weeks later, pilot indicated he had continued to fly.

Additional Npsy Testing

• COWAT (21) Borderline 11th %ile• Category Test (69 e’s) Below average 5th %ile• Iowa Gambling Test Low average 16th %ile• Cognitive Est Test Above average 92nd %ile• TPT:

• Dominant Average 56th %ile• Non-dominant Average 53rd %ile• Both Average 39th %ile• Mem/Location Average 37th %ile

Opinions

• 1. 2nd NP eval indicated evidence of neurocognitive decline/deficit that could negatively impact aeromedical safety [CFR § 67-109, 209, 309].

• 2. Due to possible change in neurological status, neurological work-up, including brain imaging, is recommended. [Results raised question of brain tumor].

• 3. Repeat Npsy evaluation recommended in 6 to 12 months.

Communication with & FAA ACTIONS

• Initial f/up with OKC indicated that medical certificate had been denied pending pilot’s follow-through with Neurological work-up & repeat Npsy assessment including CogScreen AE.

• Subsequent follow-up with Washington, DC revealed that pilot had actually been issued medical certificate 2 weeks after Npsy evaluation!

• Upon re-review, DC revoked medical certificate pending results of neurological work-up and repeat Npsy evaluation.

Work-up per FAA Recommendations

• Neurological Work-up:• Normal neurological examination;• MRI 3T of brain: Normal—no evidence of tumor or TBI

• Sleep Study (Oct/2015) – Abnormal>>OSA: • Presence of frequent obstructive hypopneas;• REM sleep respiratory instability noted;• Reduced amount of time spent sleeping in N3 and REM sleep;• Avg: SpO2: 94%• Low SpO2: 90%• SpO2 <88% for 0% pf TST.• Clinically insignificant periodic limb movements during sleep.

Little mention of OSA in Neuropsychological Textbooks

Morgan & Ricker (Eds) (2008, <1 page) Textbook of Clinical Neuropsychology: Impaired memory, thinking, perception, spatial abilities, attention, and problem-solving.

Kolb & Whishaw (2009) Fundamentals of Human Neuropsychology: One mention in Subject Index but no description of possible cognitive sequelae.

Morgan et al (2011) Casebook of Clinical Neuropsychology: No citations in Subject Index

Schoenberg & Scott (Eds) (2011) The little black book of neuropsychology: No citations in Subject Index.

Lezak et al (2012, <1 page): Visual memory and speeded tasks, and executive dysfunction related to attentional problems.

Published literature on OSA is Growing

Lal et al (2012) Neurocognitive impairment in obstructive sleep apnea, Chest, 141(6): 1601-1610.

Bucks, R.S., Olaithe, M., & Eastwood, P (2012) Neurocognitive function in obstructive sleep apnoea: A meta-review, Respirology, 18(1): 61-70.

Krisa, K, Bratek, A, Zawada, K., & Stepanczak, R (2017) Cognitie deficits in adults with obstructive sleep apnea compared to children and adolescents, Journal of Neural Transmission, (124(Supp 1): 187-201.

Olaithe, M., Bucks, R.s., Hillman, D.R., & Eastwood, P.R. (2017) Cognitive deficits in sleep apnea: Insights from a meta-review and comparison with deficits in COPD, insomnia, and sleep deprivation, Sleep Medicine Review [Epub ahead of print: 2017 Mar 30. Pii: S12087-0792(17)30070-9]

Gagnon, K, Baril, A, Gagnon, J, Fortin, M, Decary, A, Lafond, C, Desautels, A, Montplaisir, J., & Gosselin, N (2014) Cognitive impairment in obstructive sleep apnea, Pathologie Biologie, 62(5): 233-240).

Zhou, L, Chen, P, Peng, Y, and Outang, R (2016) Role of Oxidative stress in the neurocognitive dysfunction of obstrutive sleep apnea syndrome, Oxidative Medicine and Celluar Longevityy, [http://dx.doi.org/10.1155/2016/9626831]

Cognitive difficulties associated with OSA

Attention/vigilanceVerbal memory (delayed)Visual memory (delayed)Visuospatial/constructional abilitiesExecutive functioningHowever, there is variability among studies as to what

cognitive difficulties are detected

+ Relationship between OSA severity and cognition+ Relationship between treatment status & cognition

Pilot Status at Follow-up December 2015

• OSA: Had been on CPAP for 42 days (6 weeks)• Compliance data automatically sent to Sleep

Specialist.• Avg sleep: 7:40 to 7:50 per CPAP monitoring

results.

• Pilot Observations: • More refreshed upon awakening;• Less tired during the day;• Increased dreaming;• Lumosity performance comparable AM vs PM.

Follow-up CogScreen-AE (Dec. 2015)Abnormal scores in Red

MUC: Gp 1 12/16/2015 03/02/15 03/23/13Index--.05 # Scores Percentile T-Score # Scores # Scores

Speed 0 >40 >47 8 3

Accuracy 1 52.5 51 2 1

Thruput 1 35 46 7 4

Process 0 >35 >45 2 1

LRPV .0097 .9753 .3053Index --.15

Speed 2 60 53 8 7

Accuracy 2 57.5 52 4 3

Thruput 2 55 51 9 6

Process 0 >72.5 >55 3 1

Follow-up CogScreen-AE (Dec. 2015)Abnormal scores in Red

Taylor Aviation Factor Scores 12/16/15 03/02/15 03/05/13Attribute Identification 56.96 13.16 47.17Motor Coordination 70.97 63.33 63.33Visual Association Memory 55.63 48.67 54.51Speed/Working Memory 56.24 47.89 45.52Tracking 63.59 63.99 62.71

Two-year Follow-up

As of July 2017 Pilot had:• Received 1st class medical

recertification.• Was flying with a regional carrier for a

major US airline.• No problems noted by pilot and none

observed by company or other pilots.

Considerations

• 1) The objectives of Aviation Neuropsychological Evaluations should include addressing statutory issues as well as making recommendations when appropriate.

• 2) Undetected neurological issues can contribute to abnormalCogScreen-AE and neuropsychological test performance.

• 3) Untreated OSA can lead to significant difficulties in attention,vigilance, working memory, verbal and visual memory, visual spatial and construction abilities, and executive dysfunction.

• 4) OSA symptoms, at least in this case, can present as focal dysfunction.

Thank You and Safe TravelsSmith Ferry, Idaho 08/21/2017