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TESIS DOCTORAL Apnea Obstructiva Del Sueño Y Funcionamiento

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TESIS DOCTORAL Apnea Obstructiva Del Sueño Y Funcionamiento DEPARTAMENTO DE PSICOLOGÍA BÁSICA, PSICOBIOLOGIA Y METODOLOGÍA DE LAS CIENCIAS DEL COMPORTAMIENTO TESIS DOCTORAL Apnea Obstructiva del Sueño y Funcionamiento Ejecutivo Paulo Jorge Sargento dos Santos Salamanca 2015 Dª. Mª VICTORIA PEREA BARTOLOME. Dra. en Medicina y Cirugía. Especialista en Neurología. Catedrática de Universidad. Area de Psicobiología. Dpto. de Psicología Básica, Psicobiología y Metodología de las Ciencias del Comportamiento. Facultad de Psicología. Universidad de Salamanca. Dª. VALENTINA LADERA FERNANDEZ. Dra. en Psicología. Profesora Titular de Universidad. Area de Psicobiología. Dpto. de Psicología Básica, Psicobiología y Metodología de las Ciencias del Comportamiento. Facultad de Psicología. Universidad de Salamanca. CERTIFICAN: Que el trabajo, realizado bajo nuestra dirección por D. PAULO JORGE SARGENTO DOS SANTOS, licenciado en Psicología y alumno del Programa de Doctorado “Neuropsicología Clínica” titulado, “Apnea Obstructiva del Sueño y Funcionamiento Ejecutivo”, reúne los requisitos necesarios para optar al GRADO DE DOCTOR por la Universidad de Salamanca. Salamanca, abril de 2015 Fdo.: Mª Victoria Perea Bartolomé Fdo.: Valentina Ladera Fernández El dulce recuerdo de mis abuelos, José y João, mis abuelas, Ilda y Aida, mi tío Carlos, mis amigos Xico e Rui Pimpão Agradecimientos Agradecimientos y reconocimientos Lo primero y más importante de todo, quiero agradecer a las Directoras de esta tesis, Profesora Dra. María Victoria Perea y Profesora Dra. Valentina Ladera, que la han dirigido mediante la promoción de la autonomía y la búsqueda del conocimiento, sino también, como se ya se ha indicado en otra parte, me han llevado por el feliz hallazgo de la Neuropsicología: ¡MUCHAS GRACIAS, MAESTRAS! A la Universidad de Salamanca, por darme el gran privilegio de ser su alumno. A todos los Profesores del Programa de Doctorado en Neuropsicología Clínica, por la forma personal, siempre amable y competente, que nos han enseñado. A todos mis compañeros del Programa de Doctorado en Neuropsicología Clínica (en especial, a Rita Lourenço). A la Universidade Lusófona de Humanidades e Tecnologias, de Lisboa, donde trabajo, hace 23 años. A los dirigentes de la Universidade Lusófona de Humanidades e Tecnologias, de Lisboa, en las personas del Presidente del Consejo Superior Universitario del Grupo Lusófona, Profesor Dr. F. Santos Neves, del Administrador del Grupo Lusófona, Profesor Dr. Manuel de Almeida Damásio, del Administrador Adjunto, Profesor Dr. Manuel José Damásio, del Rector de la Universidade Lusófona de Humanidades e Tecnologias, Profesor Dr. Mário Moutinho, y del Decano, Profesor Dr. A. Pereira Brandão. Al Director de la Escuela de Psicología y Ciencias de la Vida, de la Universidade Lusófona de Humanidades y Tecnologias, Profesor Dr. Carlos Poiares, porque, fraternalmente, creyó en mí. A mi compañera Profesora Alexandra Figueira, por hacer siempre lo que yo no hacía, con una sonrisa. i Agradecimientos Al Profesor Dr. Nuno Colaço, porque es un ejemplo de trabajo y responsabilidad y porque también sabe serlo “Preto no Branco”. A todos mis compañeros de la Universidad, pero muy en especial a los Profesores Pedro Gamito, Jorge Oliveira, Diogo Morais y Paulo Lopes, por su espíritu innovador y ejemplo de solidaridad; sino también a la Profesora Maria Louro por su presencia siempre fraterna y al Profesor Jorge Ferreira por su gran amistad e incentivos. A Dª Carla Madeira y Dª Graça Rosário, secretarias de la Escola de Psicologia e Ciencias da Vida, por su paciencia infinita. Al Profesor Dr. Américo Baptista y a la Profesora Isaura Lourenço, por animarme a realizar este Programa de Doctorado. A mi equipo de “Clínica e Psicologia”, Manuela Lucas, Regina Afonso, Maria Castelo y Miguel Faria, gracias por todo lo que han hecho por mí y por la clínica. Un reconocimiento muy especial a Regina Afonso, por su espíritu de lucha e innovación e incondicional colaboración y amistad. Sin su calurosa y especial presencia la “Clínica e Psicologia” ya no existiría y esta tesis no llegaría a su fin: ¡MUCHAS GRACIAS! A mi compañera de muchas luchas, Dª Mercedes Batalla, por su inmenso sentido de solidaridad y justicia. Al Profesor Carlos Fernandes da Silva, de la Universidad de Aveiro, por su gran disponibilidad, solidaridad e incentivos. A los Dr. João Pedro Leandro, del Hospital Amadora/Sintra, Júlio Cardoso, del Hospital de Santa Cruz, Inês Vicente, del Hospital de Covilhã, y Pilar Rente, de la Clínica do Sono, doy las gracias a todos por su enorme disponibilidad. A Dª Patricia Afonso y Dª Lurdes Afonso, por su gran esfuerzo en los contactos con las instituciones de salud. ii Agradecimientos A todos los pacientes y voluntarios que han participado en el estudio: ¡MUCHAS GRACIAS! ¡A mis AMIGOS Luis Freire, António Estevinha, João Taborda, Hernâni Carvalho, Victor Santos Oliveira y Sérgio Félix: Gracias por su Amistad! ¡A mis fraternales compañeros, con quienes tengo una cadena de unión! Y siempre, siempre, a mis padres, hermanos y sobrinos, por ser mi puerto seguro; a Konstança, mi perra, porque me ha enseñado que el verdadero motor del desarrollo es el Amor; por último, pero no en el último lugar, a Beta, mi mujer ¡porque su Amor es Vida! ¡Y esta vida se llama Beatriz, mi muy amada hija! iii Índice Índice RESUMEN 1 ABSTRACT 3 INTRODUCCIÓN 5 PARTE 1. MARCO TEÓRICO 11 CAPÍTULO 1. EL SUEÑO 12 1.1. Introducción 13 1.2. Neurofisiología del Sueño 18 1.3. Neuroanatomía y Neuroquímica del Sueño 26 CAPÍTULO 2. TRASTORNOS DEL SUEÑO. APNEA OBSTRUCTIVA DEL SUEÑO 34 2.1. Clasificación de los Trastornos del Sueño 35 2.2. Apnea Obstructiva del Sueño 40 2.2.1. Definición 40 2.2.2. Prevalencia 46 2.2.3. Factores de riesgo 48 2.2.4. Fisiopatología 54 2.2.5. Consecuencias y condiciones asociadas más frecuentes 56 2.2.6. Tratamiento 60 CAPÍTULO 3. FUNCIONES EJECUTIVAS 64 3.1. Definición 65 3.2. Correlatos Neuroanatómicos 70 3.3. Evaluación de las funciones ejecutivas 76 3.4. Validez estructural del constructo funciones ejecutivas 84 CAPÍTULO 4. APNEA OBSTRUCTIVA DEL SUEÑO, FUNCIONAMIENTO EJECUTIVO, AJUSTE EMOCIONAL y CALIDAD DE VIDA 94 4.1. Déficits cognitivos asociados a la Apnea Obstructiva del Sueño 95 4.2. La Apnea Obstructiva del Sueño y el Funcionamiento Ejecutivo 101 4.3. Apnea Obstructiva del Sueño, Ajuste Emocional y Calidad de Vida 109 PARTE II. ESTUDIO EMPÍRICO 114 CAPÍTULO 5. OBJETIVOS E HIPÓTESIS 115 5.1. Objetivos de la investigación 116 5.1.1. Objetivos generales 117 5.1.2. Objetivos específicos 118 5.2. Hipótesis 119 CAPÍTULO 6. METODOLOGÍA 123 6.1. Diseño 124 iv Índice 6.2. Definición de variables 124 6.3. Participantes 128 6.4. Instrumentos de medida 136 6.5. Procedimiento 176 6.6. Consideraciones éticas para la realización del presente estudio 178 6.7. Análisis estadísticos realizados 179 CAPÍTULO 7. RESULTADOS 181 7.1. Análisis de normalidad de las variables en estudio 182 7.2. Funciones ejecutivas 184 7.3. Ajuste emocional 192 7.4. Calidad de vida 193 7.5. Funciones ejecutivas y ajuste emocional 198 7.6. Funciones ejecutivas y calidad de vida 204 CAPÍTULO 8. DISCUSIÓN 211 CAPÍTULO 9. CONCLUSIONES 228 REFERENCIAS 234 v Índice de Tablas Índice de Tablas Tabla 1. Sueño normal 25 Tabla 2. Hipnograma normal 25 Tabla 3. Principales neurotransmisores que participan en la regulación del ciclo sueño-vigilia 33 Tabla 4. Procedimientos en el Test de Latencias Múltiples del Sueño 39 Tabla 5. Definiciones aceptadas de los principales eventos respiratorios en el Documento de Consenso Nacional sobre el Síndrome de Apnea e hipopnea del Sueño del Grupo Español del Sueño 42 Tabla 6. Estudios de prevalencia de la Apnea Obstructiva de Sueño 47 Tabla 7. Componentes de las Funciones Ejecutivas 69 Tabla 8. Clasificación de los tests de Funcionamiento Ejecutivo y propiedad de los niveles de valoración 82 Tabla 9. Tests tradicionalmente empleados en la valoración del Funcionamiento Ejecutivo 83 Tabla 10. Tests más frecuentemente utilizados para la valoración del Funcionamiento Ejecutivo en la Apnea Obstructiva de Sueño 105 Tabla 11. Descriptivos: edad y escolaridad 132 Tabla 12. Descriptivos. Mini Mental State Examination 133 Tabla 13. Descriptivos. Escala de Somnolencia de Epworth y Cuestionário de Riesgo de Apnea de Sueño 134 Tabla 14. Descriptivos. Índice de Barthel e Índice de Lawton y Brody 135 Tabla 15. Frecuencias de la variable género en cada grupo 135 Tabla 16. Descriptivos: edad y escolaridad por genero 135 Tabla 17. Resultados medios de la ESE por severidad de Apnea Obstructiva de Sueño 138 Tabla 18. Tests a la Normalidad (Variables relativas a las Funciones Ejecutivas) 183 Tabla 19. Tests a la Normalidad (Variables relativas al Ajuste Emocional) 183 Tabla 20. Tests a la Normalidad (Variables relativas a la Calidad de Vida) 184 Tabla 21. Comparaciones apareadas para la puntuación total global de la Batería de Evaluación Frontal (Test de Mann Whitney; corrección de Bonferroni) 185 Tabla 22. Comparaciones apareadas para el Span de Dígitos al inverso (Test de Mann Whitney; corrección de Bonferroni) 185 Tabla 23. Comparaciones apareadas para la Generación Fonética – letra P (Test de Mann Whitney; corrección de Bonferroni) 186 Tabla 24. ANOVA de un factor. Generación semántico (animales) y fluidez de acciones (verbos) 186 Tabla 25. HSD de Tukey. Generación semántica (animales) y fluidez de acciones (verbos) 187 Tabla 26. ANOVA de un factor. Porcentaje de errores perseverativos en el Wisconin Card Sorting Test 187 Tabla 27. HSD de Tukey. Porcentaje de errores perseverativos en el Wisconsin Card Sorting Test 188 Tabla 28. Comparaciones apareadas para la sensibilidad a la interferencia – ítem 4 de la Batería de Evaluación Frontal (Test de Mann Whitney; corrección de Bonferroni) 189 Tabla 29. Comparaciones apareadas para el Ítem 1 de la Batería de Evaluación Frontal - Conceptualización (Test de Mann Whitney; corrección de Bonferroni) 190 Tabla 30. Comparaciones apareadas para el Número de respuestas correctas o vi Índice de Tablas ítems completados en la tarea Stroop Color/Palabra (Test de Mann Whitney; corrección de Bonferroni) 191 Tabla 31.
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