Diabetes & Obstructive Sleep Apnoea risk Jaynie Pateraki MSc RGN
Non-REM - REM - Both - Unrelated - Common disorders of Sleep Sleep Walking Night terrors Periodic leg movements Sleep automatism Nightmares REM sleep behaviour disorder Catathrenia (REM sleep groaning) Narcolepsy Obstructive sleep apnoea, central sleep apnoea Circadian rhythm disorders Drug effects Sleep in other medical disorders (e.g. heart failure, depression)
How common are sleep disorders? 1 in 7 people complain of a chronic sleep problem 1 in 3 complain intermittently of a sleep problem One of the commonest reasons for presenting to GP Sleep apnoea between 4% and 8% adults, approx 1% in children Restless legs 10% Sleep walking 10% Narcolepsy 0.15% Circadian disturbances 3% Sleep often disturbed by other problems, e.g. arthritis, depression
Sleep Apnoea Collapse of the upper airway repeatedly overnight whilst a person is sleeping. The collapse can be complete with total obstruction of the upper airway (apnoea) or partial (hypopnoea)
What is obstructive sleep apnoea? The term obstructive sleep apnoea is used to describe the actual obstructive events during a sleep study. The term obstructive sleep apnoea syndrome is used to describe the occurrence of obstructive abnormalities on a sleep study combined with symptoms, usually excessive daytime sleepiness Although we use the term apnoea, in reality the obstruction to breathing may not be complete (apnoea), but partial. Partial obstruction may lead to hypopnoea (under breathing). Hence sometimes called the sleep apnoea/hypopnoea syndrome
Severity of OSA MILD AHI 5 14 times per hour MODERATE AHI 15 29 times per hour SEVERE AHI 30 or greater per hour
Predisposing Factors Increasing Age (40 60 years) Male Gender Retrognathia Obesity Sedative drugs Smoking and alcohol consumption
Features of OSA Excessive daytime sleepiness Impaired concentration Snoring Unrefreshing Sleep Choking during sleep Witness apnoeas Restless sleep Irritability / personality change Nocturia Reduced libido
Prevalence of Sleep Apnoea
The Relationship Between Obstructive Sleep Apnoea & Diabetes The normal sleep cycle is closely related to endocrine and metabolic function. Numerous studies have shown a relationship between OSA and diabetes. (1,2,3,4,5). There have been various studies highlighting the relationship between insulin resistance and the development of cardiovascular disease. OSA may be associated with this relationship due to OSA-related hypoxemia, or an exaggerated sympathetic response seen with undiagnosed OR untreated OSA. (5,6) Increasing hypoxemia during sleep was independently associated with glucose intolerance, on the basis of either fasting glucose values or two hour glucose values. (3) OSA has been associated with development of insulin resistance. (1,2,3,7,8,9) OSA has been associated with higher odds of metabolic dysfunction after adjustment for age, gender, smoking status, BMI, waist circumference, and selfreported sleep duration. (3)
Prevalence of Diabetes, Obesity & OSA During the past 20 years, the prevalence of obesity and type 2 diabetes in the U.S. has increased.(10) The prevalence rate of OSA in adults with type 2 diabetes with an AHI of > 15 events/hour is 36 percent. - 49% of male participants with an AHI > 15 had type 2 diabetes (5) - 21% of female participants with an AHI > 15 had type 2 diabetes. (5) Self-reported diabetes was three to four times more prevalent in subjects with an AHI >15 (6) The incidence of developing type 2 diabetes after four years with an AHI > 15 was 1.62 when adjusted for age, sex and BMI (6) Insulin resistance and glucose intolerance is shown to rise correspondingly with increasing levels of OSA after adjusting for age, gender, race, BMI, waist circumference and smoking history.
WHY FOCUS ON OSA? OSA is common, and recognition by clinicians is low. OSA can have serious health consequences. OSA is costly to the economy. One study showed an increased risk of lost workdays before OSA diagnosis and treatment OSA is costly to public health. At least 1 million police-reported crashes (1,550 deaths, $12.5 billion in losses) are caused by driver fatigue each year in the USA. It has been projected that, if all U.S. drivers with OSA were treated with CPAP at a cost of $3.18 billion, the U.S. would save $11.1 billion in collision costs and 980 lives. Primary care practitioners can make a significant difference. PCPs are in an Ideal position to recognize and manage OSA by incorporating recommended screening, evaluation, and referral processes into daily practices. Improved diagnosis and treatment of OSA reduces morbidity and mortality, improves comorbid disease processes, and improves patient quality of life.
Epworth Sleepiness scale for measuring sleepiness. Least sleepy=0 Most sleepy=24
Screening for OSA in Primary Care Men necksize > 17 or Woman > 16 Age Men >40yrs Women >50yrs Do they snore? Do they wake feeling tired & unrefreshed? Has anyone told them that they stop breathing when asleep? Perform Epworth Questionaire 10 or greater more sleepy than expected.
Women & OSA Evidence shows that women are less likely than men to be referred to sleep services There is a predefined notion of the typical patient with OSA i.e. overweight male who snores. Women are more vigilant sleepers than men, men do not notice breath holding etc as commonly as women. Women may present with fatigue, insomnia, morning headaches, mood disturbances, depression or other symptoms that may suggest reasons other than OSA for their symptoms. A woman's risk of OSA increases as they transition through the menopause. Post menopausal women are 3 times more likely to have OSA than premenopausal women
Sleep Service:Diagnostic Tools Physical Examination & history Epworth Questionnaire Overnight Pulse Oximetry Modified sleep study (Embletta) If diagnosed with OSA a patient needs to inform the DVLA & Motor insurer of the diagnosis
Beginning of night Overnight (8 hours) oxygen saturation levels (oximetry) in OSA: >400 dips/apnoeas in total 1 st hr 2 nd hr 3 rd hr End of night 8 th hr 60 minutes
Snoring Airflow Ribcage Abdomen Embletta Example of an ambulatory non-eeg multichannel system SaO 2 Pulse
Treatment options for OSA Behavioural intervention: Weight loss, smoking cessation, reduced alcohol consumption Intra oral device
Treatment continued Pharmacological Surgery Bariatric surgery Tracheostomy when all else fails
Continuous Positive Airway Pressure (CPAP) Functions like a pneumatic splint Maintaining airway patency throughout all phases of sleep. It operates by means of a flow generator which delivers pressure through air tubing to a nasal or full face mask worn overnight. Most patients require lifelong treatment & therefore long term access to CPAP
Effects of CPAP Therapy on Diabetes Within 48 hours, significant improvements have been demonstrated in insulin sensitivity using CPAP therapy. Controlling insulin sensitivity and therefore blood glucose is the key goal for diabetes patients. After-meal blood glucose levels can be reduced with compliant CPAP therapy (10) Suggests that sustained CPAP use may be an important therapy for diabetics with sleep apnoea.
Type 2 diabetes is a major public health concern with high morbidity, mortality, and health-care costs. Recent reports have indicated that the majority of patients with type 2 diabetes also have obstructive sleep apnoea (OSA). Based on the current evidence, clinicians need to address the risk of OSA in patients with type 2 diabetes and, conversely, evaluate the presence of type 2 diabetes in patients with OSA. Tasali E, Mokhlesi B, Van Cauter. Obstructive sleep apnoea and type 2 diabetes: interacting epidemics. Chest 2008 Feb;133(2):496-506. doi: 10.1378/chest.07-0828.
References 1. Einhorn, D., et al., Endocr Pract 2007; 13;4:355-362 2. Reichmuth, K.J., et al., Am J Respir Crit Care Med 2005; 172:1590-1595 3. Punjabi, et al, Am J Epidemiol 2004; 160:521-530 4. Babu, et al., Arch Intern Med 2005; 165:447-452 5. Nilsson, et al., Diabetes Care 2004;; 27:2464-2469 6. Resnick, et al., Diabetes Care 2003; 26:702-709 7. Harsch, I.A., et al., Respiration 2004; 71:252-259 8. Vontzas, A.N., et al., J Clin Endocrinol Metab 2000; 1151-1158 9. Ip, M.S., et al., Am J Respir Crit Care Med 2000; 165:670-676 10. Chasens, E.R., The Diabetes Educator 2007; 33:475-482 11. Logan at al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens 2001;19:2271-2277 12. O Keeffe & Patterson. Evidence of supporting routine polysomnography1. before bariatric surgery. Obes Surg 2004 13. Oldenburg et al. Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail 2007;9:251-257 14. Garrigue et al. High prevalence of sleep apnoea syndrome in patients with long-term pacing, the European multicenter polysomnographic study. Circulation. 2007;15:1-7 15. Gami et al. Association of artial fibrillation and obstructive sleep apnea. Circulation. 2004;1104:364-367 16. Einhorn et al. Prevalence of sleep apnoea in population of adults with type 2 diabetes mellitus. Endocr Pract 2007;13:355-362 17. Sjostrom et al. Prevalence of sleep apnoea and snoring in hypertensive men: a population based study. Thorax 2002;57:602-607 18. Schafer et al. Obstructive sleep apnea as a risk marker in coronary artery disease. Cardiology. 1999;92:79-84