The Effect of Anxiety on Hypoglossal Nerve Stimulation Adherence and Amplitude Settings

Introduction: Anxiety has been associated with poor adherence to treatment options for obstructive sleep apnea (OSA), with several studies correlating the diagnosis with decreased continuous positive airway pressure (CPAP) compliance. However, there is little evidence on anxiety’s effect on hypoglossal nerve stimulator (HNS) adherence. We aimed to evaluate this association while also exploring the impact anxiety may have on tolerability of functional voltage settings.

Methods: We retrospectively reviewed 136 patients who had HNS implanted and activated between 2016-2023, excluding those < 6 months postop. Usage data and stimulation settings were derived from device interrogation at both activation visit and most recent office visit. Diagnosis of anxiety was confirmed via our institution’s electronic medical record system. Demographics, pre and postoperative sleep studies and Epworth Sleepiness Scale (ESS) scores were collected. Group comparisons were performed using two-sample t-test and chi-squared analyses with significance level at p < 0.05.

Results: In total, 59 patients met inclusion criteria, with interrogation data from an average postoperative period of 17 months (range = 6.2-56.5). Of them, 16 patients carried a diagnosis of anxiety; 43 did not. Demographics, BMI, and preoperative ESS did not differ between groups. Preoperative AHI4 in anxiety patients was 28.7 (12.2) vs 31 (13.9) in those without, p = 0.6. Patients with anxiety had significantly lower HNS usage than those without anxiety (18.9 hrs/wk vs 28.8 hrs/wk, p = 0.04). There was no statistical difference in patients reaching their functional voltage: 56.3% of patients with anxiety vs 60.5% in those without, p = 0.8. Mean amplitude settings were also comparable for the two groups (1.6 V (0.6) vs 1.5 V (0.7), p = 0.5). Although not statistically significant (p = 0.5), fewer patients with anxiety (37.5%) achieved treatment success (as defined by Sher’s criteria) post-HNS implant than patients without anxiety (52.2%).

Conclusions: Our data suggests that HNS adherence suffers more than reaching functional amplitude settings in patients with OSA and comorbid anxiety.