Sleep Apnea Screening and Neuropsychiatric Symptoms in Former Professional American-Style Football Players

Former professional American-style football (ASF) players may be at increased risk of sleep apnea (SA) compared with the general population. However, SA may be underdiagnosed or undertreated in former ASF players and be associated with cardiovascular, cognitive, and psychological health. The aim of this study was to characterize former professional ASF players self-reporting SA diagnoses, as well as undiagnosed players who screened positively on a validated SA instrument.

A cross-sectional survey was administered as part of the Football Players Health Study at Harvard University between 2017 and 2020. Former ASF players who signed a professional contract after 1960 were eligible to enroll. Data included demographics and football-related exposures (e.g., position and career duration), self-reported SA diagnosis, and STOP-BANG screening scores. Head injury exposure was measured using the number of concussion symptoms accrued during football practice or play. Outcomes included self-reported cognitive functioning, depression, anxiety, and pain. Multivariable logistic and linear regression was used to identify associations between sleep outcomes and (1) demographic and football characteristics and (2) recent mood, cognitive, and pain symptoms, respectively.

Among 1,951 participants, 31.8% self-reported SA diagnoses (n = 621), which were associated with older age, Black race, lineman status, and higher numbers of football-accrued concussion symptoms. Only 39.8% (n = 247) of the SA group reported using their positive airway pressure therapy 4+ times per week. Of those without a current diagnosis of SA (n = 1,330), 74.6% (n = 992) scored in the intermediate or high range on the STOP-BANG. In multivariable models adjusted for demographic and football-related exposures, SA diagnosis and intermediate/high STOP-BANG scores were associated with more pain, anxiety, depression, and cognitive symptoms. Data showed that participants with diagnosed but untreated SA reported the highest symptom burden (all p < 0.001).

This study identified that many former professional ASF players may be at risk of not being appropriately screened or treated for SA. These results estimate that the actual proportion of former professional ASF players with SA may be as high as 69%. Mood, pain, and cognitive symptoms may be exacerbated in those with treated, undertreated, or suspected SA.