The veteran population: one at high risk for sleep-disordered breathing

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1 Sleep Breath (2006) 10: DOI /s ORIGINAL ARTICLE María Elena Ocasio-Tascón Edwin Alicea-Colón Alfonso Torres-Palacios William Rodríguez-Cintrón The veteran population: one at high risk for sleep-disordered breathing Published online: 22 February 2006 # Springer-Verlag 2006 M. E. Ocasio-Tascón (*). E. Alicea-Colón. A. Torres-Palacios. W. Rodríguez-Cintrón San Juan VA Medical Center, 10 Casia Street, Pulmonary and Critical Care Section (111E), San Juan , Puerto Rico meocasio@yahoo.com Tel.: Fax: Abstract Sleep complaints are very common among the general population and are usually accompanied by significant medical, psychological and social disturbances (Redline S, Strohl K, Otolaryngol Clin North Am, 132:303, 1999). A higher prevalence of sleep complaints has been described in the elderly (Vgontzas AN, Kales A, Annu Rev Med, 50: , 1999). It is manifested by breathing disturbances during sleep, loud snoring, difficulties maintaining sleep, fatigue, daytime sleepiness, mood effects and impairment of daily activities (Lugaresi E, Cirignotta F, Zucconi M et al., Good and poor sleepers: an epidemiological survey of the San Marino population, Raven, New York, pp 1 12, 1983; Kales A, Soldatos CR, Kales JD, Am Fam Physician, 22: , 1980). It has been associated with cardiovascular, endocrine and neurocognitive manifestations. Growing interest in early diagnosis and treatment has been noted in recent years based on emerging knowledge about the potential health consequences when the disease goes untreated (Nanen AM, Dunagan DP, Fleisher A et al., Chest, 121:1741, 2002). The veteran population in the mainland has a higher tendency for obesity, high blood pressure (HBP), sleep disorders and chronic alcohol consumption (Mustafa M, Erokwu N, Ebose I, Strohl K, Sleep Breath, 9:57 63, 2005). The Hispanic veteran population has never been studied in detail for sleep disorders and related conditions. We used previously validated screening tools for sleep disturbance breathing. Two hundred and forty-five questionnaires were administered. We found a higher prevalence of Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) in our population compared with data from the mainland (USA). The mean age was 64 years (±11). Ninety seven per cent were males. The mean body mass index was 25 kg/cm 2 ; mean Epworth Sleepiness Scale score was 8. Thirty-four per cent met highrisk criteria for sleep apnea, 53% for insomnia, 13% for symptoms suggestive of narcolepsy and 13% for those suggestive of restless leg syndrome. There were high incidences of alcohol consumption (37.6%), diabetes (32.7%), hypercholesterolemia (31.8%), depression (31.8%), hypertension (39.6%) and post-traumatic stress disorder (PTSD) (9.8%). Keywords Sleep-disordered breathing. Sleep apnea. Veterans. Post-traumatic stress disorder. Hypertension. Snoring Introduction Sleep complaints are very common among the general population and are usually accompanied by significant medical, psychological and social disturbances [1]. The Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) is a common, sometimes undiagnosed and disabling condition. It affects approximately 2% of women and 4% of men, though higher prevalence has been described in the elderly [2]. It is manifested by breathing disturbances during sleep, loud snoring, difficulties maintaining sleep, fatigue, daytime sleepiness, mood effects and impairment of daytime activities [3, 4]. It has been associated with the development of hypertension (high

2 71 Table 1 Population description (n=245) Male % Hispanic % Black 12 5% White 44 18% African American 2 1% blood pressure, HBP) [1, 5], ischemic heart disease [6, 7], congestive heart failure (CHF) [7, 8], stroke [9], insulin resistance and neurocognitive dysfunction [10]. In the United States, the prevalence of risk factors for the development of OSAHS in primary care offices is many times higher than the physician-diagnosed sleep apnea [11]. Among five Cleveland adult primary care offices, an average prevalence rate of high risk for OSAHS was in excess of 30% [12]. A similar survey done in Puerto Rico showed that 58% of the sample was at high risk for sleepdisordered breathing (SDB) [13]. Growing interest in early diagnosis and treatment has been noted in recent years based on emerging knowledge about the potential health consequences of untreated disease [14]. In the Unite States, there was a 12-fold increase in patients diagnosed annually with sleep apnea between 1990 and 1998 from 108,121 to 1,305,624 diagnoses [15]Appropriate identification of high-risk patients requires high clinical suspicion and an understanding of risk factors for the development of OSAHS. Diagnostic tools have been developed during the last decade including diagnostic equipment, techniques and screening questionnaires. Clearly defined risk factors for the development of OSAHS include male gender and obesity. Other risk factors include craniofacial features, underlying cardiopulmonary disease, diabetes, genetic factors, environmental exposure that increase airway inflammation and neuromuscular dysfunction (including decreased neuromuscular output of upper airway muscles induced by alcohol or sedatives) [1]. The veteran population on mainland USA has been described as one with higher tendency for obesity, HBP, sleep disorders and chronic alcohol consumption [16]. The population served by the San Juan VAMC (San Juan, Puerto Rico) is mainly composed of Hispanics and has never been studied in detail for sleep disorders and related conditions. We proposed to survey the population served by the San Juan Veterans Administration Center (SJVAMC) anonymously, for a range of sleep complaints using a self-report instrument developed and implemented in non-va populations in Cleveland. The instrument is the Cleveland Sleep Habits Questionnaire (CHSQ). Methods The cleveland sleep habits questionnaire The Cleveland Sleep Habits Questionnaire (CSHQ) is a self-report instrument that is a direct extension of the Berlin Questionnaire. It includes three categories divided as sleeprelated questions, chronic fatigue and daytime sleepiness related questions and body mass index (BMI). It includes the Epworth Sleepiness Scale, a standardized eightquestion instrument designed to give a subjective estimate for passive sleepiness. It has a maximal score of 24. Table 2 Self-reported comorbidities from the Cleveland Questionnaire ETOH Active alcohol consumption, MI myocardial infarction, CHF congestive heart failure, CVA cerebrovascular accident, COPD chronic obstructive pulmonary disease, PTSD post-traumatic stress disorder, OSA obstructive sleep apnea, RLS restless leg syndrome Self-reported condition N=245 Per cent Smoking ETOH Diabetes Hypercholesterolemia MI Nocturnal Angina Depression Hypothyroidism Asthma Hypertension CHF CVA COPD PTSD OSA Nasal allergies Insomnia Narcolepsy RLS Epworth >

3 72 Fig. 1 Categories of the Berlin Questionnaire as predictors for obstructive sleep apnea (OSA). Category I Snoring, category II daytime sleepiness, category III hypertension, obesity Normal subjects generally score less than 12 points. The CSHQ also includes a brief checklist of medical conditions. Population Subjects were randomly recruited from the five ambulatory clinics served by the SJVAMC. For a population of 49,426 ambulatory patients, an expected prevalence of 20%, a margin of error of 5% and a confidence interval of 95%, a sample of 245 subjects was required. Survey distribution The physician arrived at each centre during the morning and randomly distributed questionnaires. He was present during the completion of the questionnaire, and he returned the completed questionnaires to the centre. Scoring Categories were scored according to response to questions related to snoring (category I), daytime sleepiness/fatigue (category II), HBP and/or BMI >31 (category III). For a patient to be at high pretest probability for OSAHS, at least two out of three categories need to be present. The investigator physician handed out 245 questionnaires to subjects who attended each ambulatory primary care clinic between the months of November 2001 and February Fig. 2 Pretest probability for OSA according to self-reported comorbidities. None reached statistical significance. HTN Hypertension, COPD chronic obstructive pulmonary disease, Chol hypercholesterolemia, MI myocardial infarction, CHF congestive heart failure, Noc Angina nocturnal Angina Percent at high pre-test probability for OSA 60% 50% 40% 30% 20% 10% Risk factor present Risk factor absent 0% HTN COPD Chol Nasal Allergy MI Asthma CHF Noc Angina

4 73 Fig. 3 Per cent at high pretest probability for OSA according to self-reported medical conditions and Epworth scale score. PTSD Post-traumatic stress disorder. *p<0.05, p<0.01 Percent at high risk for OSA 90% 80% 70% 60% 50% 40% 30% 20% Risk factor present Risk factor absent 10% 0% PTSD Depression Insomnia Narcolepsy Epworth>12 Statistical analysis The Student s t test was used for continuous variables. Chisquare test was applied to categorical variables. A univariate logistic regression was used to calculate odds ratio for the relationship between OSAHS and the other evaluated variables. All significant variables that correlated with the outcome measures in the univariate analysis were subsequently included in the multiple logistic regression model. A p value of 0.05 or less was regarded as statistically significant. Results As shown in Table 1, our population consisted mainly of Hispanic males with a mean BMI of 25 kg/cm 2 with a mean age of 64 years (±0.11). The mean Epworth score reported was 8. The Epworth score higher than 12 was reported in 24% of the sample. The most common sleep complaint was insomnia (53%). Symptoms suggesting narcolepsy and restless leg syndrome (RLS) were identified in 13 and 14%, respectively (Table 2). There was a high incidence of alcohol consumption (37.6%), diabetes (32.7%), hypercholesterolemia (31.8%), depression (31.8%), hypertension (39.6%) and post-traumatic stress disorder (PTSD) (9.8%) among our population. Previously diagnosed OSA was reported by 4.5% of the sample. Thirty-four per cent of the sample was found with a high pretest probability for OSAHS. Of the three categories of the CSHQ, the most sensitive (89%) for screening for OSAHS was category II (sleepiness questions), followed by category III (78%) and category II (65%). On the other hand, the most specific category for high pretest probability for OSAHS was category I (snoring-related questions), being 95% specific (Fig. 1). Of the patients who reported hypertension, there was a higher number with high pretest probability for OSAHS (p<0.001). There was a tendency for higher incidence for OSAHS in patients who reported chronic obstructive pulmonary disease (COPD), nasal allergies and nocturnal angina, but none of these reached statistically significant values (Fig. 2). There was a higher number of subjects with high pretest probability for OSAHS among those who reported PTSD compared with those who did not. A higher risk for OSAHS was also noted in patients with depression, insomnia, narcolepsy symptoms and Epworth scale >12 (Fig. 3). Discussion This study has demonstrated a high prevalence of risk factors for OSAHS in our population when compared with the general population but lower than the recently reported data from veterans on the mainland USA [16]. Much of the previous research evidence for a possible causal relationship between OSA and cardiovascular diseases (CVD) has been focused on hypertension. Our data support this relation. A recent study done in Sweden investigated the development of CVD in previously healthy men free of hypertension and other CVD at baseline during a 7-year follow-up. It confirmed the higher prevalence of CVD in those patients with OSA and also in those with incompletely treated OSA [17]. Understanding the economic impact and the high prevalence of CVD in our sample would guide us towards early detection and treatment. Previous studies have reported that insomnia affects as many as one fifth of all patients who consult general physicians [18]. A higher proportion was noted in our sample. The Wisconsin Sleep Cohort Study demonstrated that men with five or more apneas/hypopneas per hour of

5 74 sleep were three to four times more likely to have an automobile accident in the previous 5 years than men without SDB [19]. Another study done in Spain which followed patients who received emergency treatment after motor vehicle accidents found that patients with an apnea/ hypopnea index higher than 10 had an odds ratio of 7.2 for having a traffic accident despite adjustments for alcohol, visual acuity, age and distance driven per year [20]. The relation of sleep disorders and motor vehicle accidents has not been studied on our island. Data obtained from the local department of transportation from January 1997 and December 1998 revealed that 793 car accidents were related to drivers described as fatigued by the interviewing police officer, 14 of them being fatal accidents. Sleepiness, fatigue and inattention are major proximate causes not only of car crashes but also personal accidents and workplace errors. Sleep apnea is only one cause; more often, people do not value sleep or plan on enough sleep to be better rested. Reductions in sleepiness either by advocating sleep extension or recognizing a sleep disorder reduce the adverse events and the sense of wellness [2, 21]. Early recognition and treatment of SDB and its complications will result in overall reduction in health-related costs. A significant number of patients reported symptoms suggesting RLS and narcolepsy, which are higher than the expected for the general population, and both correlated with a high pretest probability for OSAHS. Both relations have been previously described in the literature. The CSHQ was not validated for the detection of these disorders, but specific questions regarding the accompanying symptoms of these conditions are included. A high incidence of depressive symptoms was also noted in our sample (31.8%), which is higher than the expected for primary care offices and which has been reported in 5 10% of the patients. An expected positive correlation was identified as well. PTSD was reported in 9.8% of our sample, which is higher than the general population (5 6%) but not unexpected due to the higher exposure to military combat and other stressful events in this sample. A higher pretest probability for OSAHS was noted in patients with PTSD (p<0.05). To our knowledge, this is the first report in which an association between PTSD and sleep apnea is established. The questionnaire by itself cannot establish a causal relation and does not correct for medication use or head injuries related to the traumatic event. Whether OSHAS predisposes to PTSD as it does with other neuropsychological manifestations or PTSD manifests itself as muscle tone changes and, consequently, apnea is not clear at this time; however, this relation certainly warrants future investigation. Hispanic veterans have high prevalence for pretest probability for sleep apnea when compared with the general population. This group also reports chronic symptoms for other sleep disorders. Although only screening questionnaires were used and no confirmatory tests were performed, these data are of value for future research. These questionnaires are simple, non-invasive measures to detect possible sleep disorders. All health care professionals have an important role in recognizing SDB amenable for effective treatment. References 1. Redline S, Strohl K (1999) Recognition and consensus of obstructive sleep apnea hypopnea syndrome. Otolaryngol Clin North Am 132(2): Vgontzas AN, Kales A (1999) Sleep and its disorders. Annu Rev Med 50: Lugaresi E, Cirignotta F, Zucconi M et al (1983) Good and poor sleepers: an epidemiological survey of the San Marino population. In: Guilleminault C, Lugaresi E (eds) Sleep/wake disorders: natural history, epidemiology and long-term evolution. Raven, New York, pp Kales A, Soldatos CR, Kales JD (1980) Taking a sleep history. Am Fam Physician 22: Kales A, Vela-Bueno A, Kales JD (1987) Sleep disorders: sleep and narcolepsy. Ann Intern Med 106: Gislason T, Aberg H, Taube A (1987) Snoring and systemic hypertension an epidemiologic study. Acta Med Scand 222: Hung J, Whitford EG, Parsons RW et al (1990) Association of sleep apnea with myocardial infarction in men. Lancet 336: Malone S, Liu PP, Holloway R, Rutherford R, Zie A, Bradley TD (1991) Obstructive sleep apnea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure. Lancet 338: Partinen M, Guilleminault C (1988) Daytime sleepiness and vascular morbidity at seven-year follow-up in obstructive sleep apnea patients. Chest 94: Quan S, Howard B, Iber C, Kiley J, Nieto J, O Connor G, Rapoport D, Redline S et al (1997) The sleep heart study: design, rationale, and methods. Sleep 20: Young T, Evans L, Finn L, Palta M (1997) Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 20:

6 Netzer N, Stoohs R, Netzer C, Clark K, Strohl K (1999) Using the Berlin questionnaire to identify patients at high risk for the sleep apnea syndrome. Ann Intern Med 131: Blondet M, Yapor P, Rodriguez W (2001) The Berlin questionnaire in Puerto Rico: a need for education and treatment. Am J Respir Crit Care Med 163:A Nanen AM, Dunagan DP, Fleisher A et al (2002) Increased physician reported sleep apnea: the national ambulatory medical care survey. Chest 121: Namen A, Dunagan D, Fleisher A, Tillet J, Barnett M, Mc Call W, Haponik E (2002) Increased physicianreported sleep apnea: the national ambulatory medical care survey. Chest 121: Mustafa M, Erokwu N, Ebose I, Strohl K (2005) Sleep problems and the risk for sleep disorders in an outpatient veteran population. Sleep Breath 9: Peker Y, Hedner J, Norum J, Kraikzi H, Carlson J (2002) Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea. A 7- year follow-up. Am J Respir Crit Care Med 166: Kales A, Soldatos CR, Kales JD (1980) Taking a sleep history. Am Fam Physician 22: Young T, Blustein J, Finn L, Palta M (1997) Sleep-disordered breathing and motor vehicle accidents in a population based sample of employed adults. Sleep 20: Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara et al (1999) The association between sleep apnea and the risk of traffic accidents. N Engl J Med 340: Dement WC, Netzer NC (2000) Primary care: is the setting to address sleep disorders? Sleep Breath 4:1 6

Underdiagnosis of Sleep Apnea Syndrome in U.S. Communities

ORIGINAL ARTICLE Underdiagnosis of Sleep Apnea Syndrome in U.S. Communities Vishesh Kapur, M.D., 1 Kingman P. Strohl, M.D., 2 Susan Redline, M.D., M.P.H., 3 Conrad Iber, M.D., 4 George O Connor, M.D.,