For Doctors in a Hurry
- Clinicians need to determine the prevalence and clinical impact of sleep apnea among former professional American football players.
- The study surveyed 1,951 former players between 2017 and 2020 to assess sleep apnea diagnoses and screening scores.
- Researchers found that 31.8 percent reported a diagnosis, while 74.6 percent of undiagnosed players screened as high risk.
- The authors conclude that sleep apnea is likely underdiagnosed, with an estimated 69 percent of players potentially affected.
- Physicians should prioritize screening for sleep apnea to address associated pain, anxiety, depression, and cognitive symptoms in this population.
Sleep Pathology and Neuropsychiatric Health in Collision Sport Athletes
Elite athletes are frequently subject to unique physiological stressors that can lead to chronic health challenges long after their competitive careers conclude [1, 2]. Among these challenges, sleep disturbances are increasingly recognized as a critical factor influencing both cognitive function and long-term neurological health [3]. While the prevalence of obstructive sleep apnea in the general young adult population is estimated at approximately 16%, athletes in collision sports may face significantly higher risks due to specific physical profiles and injury histories [4, 5]. Furthermore, sleep disorders frequently co-occur with concussion-related symptoms and may complicate the clinical presentation of suspected neurodegenerative conditions [6, 7]. Understanding the intersection of sleep pathology and neuropsychiatric health is essential for clinicians managing the complex needs of former professional players, as sleep disordered breathing represents a potentially modifiable risk factor for cognitive and psychological decline.
The researchers conducted a cross-sectional survey as part of the Football Players Health Study at Harvard University between 2017 and 2020, recruiting a large cohort to evaluate the intersection of athletic exposure and sleep health. The study population consisted of 1,951 former professional American-style football players who had signed a professional contract at any point after 1960. Data collection was comprehensive, encompassing participant demographics and specific football-related exposures, including player position and total career duration. To assess the prevalence of sleep disorders, the authors collected self-reported sleep apnea diagnoses and utilized the STOP-BANG instrument, which is a validated eight-item screening tool that evaluates snoring, tiredness, observed apnea, blood pressure, body mass index, age, neck circumference, and gender. This tool is particularly useful in clinical settings for identifying patients at high risk for obstructive sleep apnea who may require formal polysomnography.
Beyond sleep metrics, the study quantified head injury exposure by calculating the total number of concussion symptoms accrued during football practice or active play, providing a proxy for cumulative neurological strain. These data were then correlated with several clinical outcomes measured via self-reported cognitive functioning, depression, anxiety, and pain. To ensure the accuracy of these associations, the researchers employed multivariable logistic and linear regression models, which are statistical techniques used to isolate the specific impact of sleep apnea while controlling for confounding factors like age or career length. This rigorous approach revealed that participants with diagnosed but untreated sleep apnea reported the highest symptom burden across all measured categories, with a statistical significance of p < 0.001. For the practicing physician, this finding suggests that the neuropsychiatric symptoms often attributed solely to past head trauma may be significantly exacerbated by untreated respiratory issues during sleep.
High Prevalence and Clinical Predictors of Sleep Disordered Breathing
Analysis of the study cohort revealed a substantial discrepancy between established clinical diagnoses and current screening results, suggesting a high rate of undiagnosed pathology. Among the 1,951 participants, 31.8% (n = 621) self-reported a prior diagnosis of sleep apnea. However, this figure likely represents only a fraction of the true disease burden within this population. When the researchers evaluated the 1,330 players without a current sleep apnea diagnosis, 74.6% (n = 992) scored in the intermediate or high range on the STOP-BANG screening tool. Based on these screening data, the researchers estimate that the actual proportion of former professional players with sleep apnea may be as high as 69%, suggesting that more than two-thirds of this patient population may require clinical intervention. This gap indicates that many former athletes presenting with vague complaints of fatigue or cognitive fog may be suffering from unrecognized sleep disordered breathing.
The study identified specific demographic and professional risk factors that correlate with a higher likelihood of sleep disordered breathing, providing clinicians with a profile of the high-risk patient. Self-reported sleep apnea diagnoses were significantly associated with older age, Black race, and playing the lineman position, a role often characterized by higher body mass and larger neck circumferences, both of which are known physiological precursors to airway obstruction. Furthermore, the researchers observed a clear link between cumulative neurological trauma and sleep health; a higher number of football-accrued concussion symptoms was positively associated with a sleep apnea diagnosis. This association suggests that the cumulative burden of head injuries may contribute to or coexist with the development of sleep apnea, perhaps through damage to central respiratory drive centers or shared inflammatory pathways. This necessitates more vigilant screening for players with extensive histories of concussion symptoms to mitigate long-term cognitive and psychological morbidity.
Impact of Untreated Sleep Apnea on Neuropsychiatric Symptom Burden
Clinical management of sleep apnea in this population is significantly hindered by low treatment adherence, which remains a primary barrier to improving patient outcomes. Among the 621 players with a formal sleep apnea diagnosis, only 39.8% (n = 247) reported using positive airway pressure therapy four or more times per week, which is a common clinical benchmark for treatment compliance. Positive airway pressure therapy involves the use of a machine that delivers a continuous stream of air through a mask to prevent airway collapse during sleep. This high rate of non-adherence suggests that even when the condition is identified, a majority of former athletes remain exposed to the physiological stressors of nocturnal hypoxia (low blood oxygen levels) and sleep fragmentation.
The researchers utilized multivariable models adjusted for demographic factors and football-related exposures to evaluate the relationship between sleep health and neuropsychiatric outcomes. They found that both a formal sleep apnea diagnosis and intermediate or high scores on the STOP-BANG screening tool were significantly associated with increased pain, anxiety, depression, and cognitive symptoms. These findings indicate that mood, pain, and cognitive symptoms are exacerbated in participants across the entire clinical spectrum, including those with treated, undertreated, or suspected sleep apnea. This suggests that even subclinical sleep disordered breathing may contribute to the overall symptom burden in former athletes.
The most pronounced clinical impact was observed in the group with the least intervention, highlighting a critical opportunity for physician involvement. Participants with diagnosed but untreated sleep apnea reported the highest symptom burden across every measured outcome (p < 0.001), including psychological distress and cognitive impairment. For the practicing clinician, these data emphasize that untreated sleep disordered breathing may be a primary driver of the complex, comorbid presentations of chronic pain and neuropsychiatric decline often seen in former professional athletes. Addressing sleep apnea through aggressive screening and adherence support may therefore be one of the most effective ways to improve the quality of life and cognitive trajectory for this patient population.
References
1. Walsh NP, Halson SL, Sargent C, et al. Sleep and the athlete: narrative review and 2021 expert consensus recommendations. British Journal of Sports Medicine. 2020. doi:10.1136/bjsports-2020-102025
2. Reardon CL, Hainline B, Aron CM, et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine. 2019. doi:10.1136/bjsports-2019-100715
3. Gaggi N, Parincu Z, Peterson A, et al. Enhancing sleep, wakefulness, and cognition with transcranial photobiomodulation: a systematic review. Frontiers in Behavioral Neuroscience. 2025. doi:10.3389/fnbeh.2025.1542462
4. Zasadzińska-Stempniak K, Zajączkiewicz H, Kukwa A. Prevalence of Obstructive Sleep Apnea in the Young Adult Population: A Systematic Review. Journal of Clinical Medicine. 2024. doi:10.3390/jcm13051386
5. Groh JR, Yhang E, Tripodis Y, et al. Health outcomes of former division I college athletes.. Brain injury. 2025. doi:10.1080/02699052.2024.2405209
6. Lumba‐Brown A, Teramoto M, Bloom OJ, et al. Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery. 2019. doi:10.1093/neuros/nyz332
7. Grashow R, Eagle SR, Terry DP, et al. Medical Conditions in Former Professional American-Style Football Players Are Associated With Self-Reported Clinical Features of Traumatic Encephalopathy Syndrome. Neurotrauma Reports. 2024. doi:10.1089/neur.2024.0008
