Obstructive sleep apnea: Screenings in primary, secondary and tertiary care settings

Atmaram Yarlagadda, Jayaprada Kasaraneni, Anita H. Clayton

Department of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, USA;.
McDonald Army Health Center, Ft. Eustis, USA.
Research Assistant Vaccine and Gene Therapy OHSU, Portland, USA.

DOI: 10.4236/health.2013.58A2009                

Abstract

Insomnia is a major health problem affecting millions of people around the globe, particularly in the developed world, substantially impacting on individual work performance and raising disability costs. Insomnias can be broadly divided into primary and secondary types. Primary insomnias can further be divided into parasomnias and dyssomnias. Diagnostic approaches to insomnias can be challenging, thereby complicating the treatment process. Obstructive sleep apnea (OSA) falls under the category of primary insomnias and is a good example of frequently missed diagnoses. The goal of this paper is to document the development of a self-reporting sleep apnea scale based on graded percentage scores to correlate with primary, secondary and tertiary risks. Scores falling under fifty percent represent primary prevention risks of OSA and suggest possible interventions. A score of fifty percent highlights three core symptoms on the scale as described in detail below to represent early detection of OSA or secondary prevention. Finally, scores exceeding fifty percent will include associated risks of comorbidities as well as other factors contributing to OSA, or tertiary prevention, with separate scores assigned to individual risk factors. Analysis of final scores on the proposed scale would therefore, in our opinion help achieve the goal of grading the risk of OSA from a multidisciplinary preventive care aspect.

Keywords

Sleep Apnea; Primary Prevention; Insomnia; Obesity; Metabolic Syndrome

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Kryger, M.H. (2000) Diagnosis and management of sleep apnea syndrome. Clinical Cornerstone, 2, 39-47. doi:10.1016/S1098-3597(00)90039-5
[2]	Young, T., Evans, I., Finn, I. and Plta, M. (1997) Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle aged men and women. Sleep, 20, 705-706.
[3]	O’Keeffe, T. and Patterson, E.J. (2004) Evidence supporting routine polysomnography before bariatric surgery. Obesity Surgery, 14, 23-26. doi:10.1381/096089204772787248
[4]	Lettieri, C.J., Eliasson, A.H., Andrada, T., Khramtsov, A., Raphaelson, M. and Kristo, D.A. (2005) Obstructive sleep apnea syndrome: Are we missing an at-risk population? Journal of Clinical Sleep Medicine, 1, 381-385.
[5]	Kramer, N., Cook, T.E., Carlisle, C.C., Corwin, R.W. and Millman, R.P. (1999) The role of primary care physician in recognizing obstructive sleep apnea. Archives of Internal Medicine, 159, 965-968. doi:10.1001/archinte.159.9.965
[6]	Turkington, P.M., Sircar, M., Allgar, V. and Elliott, M.W. (2001) Relationship between obstructive sleep apnea, driving simulator performance, and risk of road traffic accidents, Thorax, 56, 800-805. doi:10.1136/thorax.56.10.800
[7]	Shahar, E., Whitney, C.W., Redline, S., Lee, E.T., Newman, A.B., Javler, F., George, N., O’Connor, T., Boland, L.L., Schwartz, J.E. and Samet, J.M. (2001) Sleep-disordered breathing and cardiovascular disease: Cross-sectional results of the sleep heart health study. American Journal of Respiratory and Critical Care Medicine, 163, 19-25. doi:10.1164/ajrccm.163.1.2001008
[8]	Netzer, N.C., Hoegel, J.J., Loube, D., et al. (2003) Prevelence of symptoms and risk of sleep apnea in primary care. Chest, 124, 1406-1414. doi:10.1378/chest.124.4.1406
[9]	Leger, D., Partinen, M., Hirshkowitz, M., Chokroverty, S., Hedner, J. and EQUINOX (Evaluation of daytime Quality Impairment by Nocturnal awakenings in Outpatient’s eXperience) (2010) Characteristics of insomnia in a primary care setting: EQUINOX survey of 5293 insomniacs from 10 countries. Sleep Medicine, 11, 987-998. doi:10.1016/j.sleep.2010.04.019
[10]	Roth, T. and Roehrs, T. (2003) Insomnia: Epidemiology, characteristics, and consequences. Clinical Cornerstone, 5, 5-15. doi:10.1016/S1098-3597(03)90031-7
[11]	Young, T., Palta, M., Dempsey, J., Skatrud, J., Weber, S. and Badr, S. (1993) The occurrence of sleep disordered breathing among middle-aged adults. The New England Journal of Medicine, 328, 1230-1235. doi:10.1056/NEJM199304293281704
[12]	Kapur, V., Strohl, K.P., Redline, S., Iber, C., O’Connor, C. and Neito, J.L. (2002) Underdiagnosis of sleep apnea syndrome in United States communities. Sleep Breath, 6, 49-54. doi:10.1055/s-2002-32318
[13]	Neito, F.J., Young, T.B., Lind, B.K., et al. (2000) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA, 283, 1829-1836. doi:10.1001/jama.283.14.1829
[14]	Gami, A.S., Caples, S.M. and Somers, V.K. (20030 Obesity and obstructive sleep apnea. Endocrinology and Metabolism Clinics of North America, 32, 869-894. doi:10.1016/S0889-8529(03)00069-0
[15]	Levers-Landis, C.E. and Redline, S. (2007) Pediatric sleep apnea: Implications of the epidemic of childhood overweight. American Journal of Respiratory and Critical Care Medicine, 176, 1054-1055.
[16]	Kajaste, S., Brander, P.E., Telakivi, T., Partinen, M. and Mustajoki, P. (2004) A cognitive-behavioral weight reduction program in the treatment of obstructive sleep apnea syndrome with or without initial nasal CPAP: A randomized study. Sleep Medicine, 5, 125-131. doi:10.1016/j.sleep.2003.07.007
[17]	Dement, W.C. and Netzer, N.C. (2009) Primary care: Is it the setting to address sleep disorders? Sleep Breath, 1, 1-9.
[18]	Chung, S.A., Jairam, S., Hussain, M.R. and Shapiro, C.M. (2001) Knowledge of sleep apnea in a sample grouping of primary care physicians. Sleep Breath, 5, 115-121. doi:10.1055/s-2001-17429
[19]	Sassani, A., Findley, L.J., Kryger, M., Goldlust, E., George, C. and Davidson, T.M. (2004) Reducing motorvehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep, 27, 453-458.
[20]	Tregear, S., Reston, J., Schoelles, K. and Phillips, B. (2010) Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: Systematic review and meta-analysis. Sleep, 33, 1373-1380.
[21]	Yee, B., Campbell, A., Beasley, R. and Neill, A. (2002) Sleep disorders: A potential role in New Zealand motor vehicle accidents. Internal Medicine Journal, 32, 297-304. doi:10.1046/j.1445-5994.2002.00229.x
[22]	Antonopoulos, C.N., Sergentanis, T.N., Daskalopoulou, S.S. and Petridou, E.T. (2011) Nasal continuous positive airway pressure (nCPAP) treatment for obstructive sleep apnea, road traffic accidents and driving simulator performance: A meta-analysis. Sleep Medicine Reviews, 15, 301-310.
[23]	Frey, W.C. and Pilcher, J. (2003) Obstrutive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obesity Surgery, 13, 676-683. doi:10.1381/096089203322509228
[24]	Biederman, J., Newcorn, I. and Sprich, S. (1991) Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. The American Journal of Psychiatry, 148, 564-577.
[25]	Frick, P.J., Kamphaus, R.W., Lahey, B., Loeber, R., Christ, M.A.G. and Hart, E.L. (1991) Academic underachievement and the disruptive behavior disorders. Journal of Consulting and Clinical Psychology, 59, 289-294. doi:10.1037/0022-006X.59.2.289
[26]	Barkley, R.A. (2006) Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. The Guilford Press, New York.
[27]	Cuccia, A.M., Campisi, G., Cannavale, R. and Colella, G. (2007) Obesity and craniofacial variables in subjects with obstructive sleep apnea syndrome: Comparisons of cephalometric values. Head & Face Medicine, 3, 41. doi:10.1186/1746-160X-3-41
[28]	Alkhali, M. and Lockey, R. (2011) Pediatric obstructive sleep apnea syndrome (OSAS) for the allergist. Annals of Allergy, Asthma & Immunology, 107, 104-109. doi:10.1016/j.anai.2011.04.004
[29]	Szabo, J. and Goldfarb, B. (2005) Metabolic syndrome risisng in adults and adolescents. DOC News, 2, 7.
[30]	Southwell, C., Moallen, M. and Auckley, D. (2008) Cardiologists knowledge and attitudes about obstructive sleep apnea: A survey study. Sleep Breath, 12, 295-302. doi:10.1007/s11325-008-0170-1
[31]	Olivarez, S.A., Ferres, M., Antony, K., Mattewal, A., Maheshwari, B., Sangi-Haghpeykar, H. and AagaardTillery, K. (2011) Obstructive sleep apnea screening in pregnancy, perinatal outcomes, and impact of maternal obesity. American Journal of Perinatology, 28, 651-658. doi:10.1055/s-0031-1276740
[32]	Ohayon, M.M. (2003) The effects of breathing-related sleep disorders on mood disturbances in the general population. Journal of Clinical Psychiatry, 64, 1195-1200. doi:10.4088/JCP.v64n1009
[33]	Yarlagadda, A., Kaushik, S. and Clayton, A.H. (2008) Obstructive sleep apnea, hypoxia, and metabolic syndrome in psychiatric and nonpsychiatric settings. Psychiatry, 5, 58-50.
[34]	Yarlagadda, A., Brown, A.B. and Clayton, A.H. (2007) Onset of sleep apnea after initiation of psychotropic agents. Letter to the editor. Primary Care Companion to the Journal of Clinical Psychiatry, 9, 471
[35]	Chung, F., Yegneswaran, B., Liao, P., Chung, S.A., Vairavanathan, S., Islam, S., Khajehdehi, A. and Shapiro, C.A. (2008) STOP Questionnaire. A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108, 812-821. doi:10.1097/ALN.0b013e31816d91b5
[36]	Drager, L.F., Polotsky, V.Y. and Lorenzi-Filho, G. (2011) Obstructive sleep apnea: An emerging risk factor for atherosclerosis. Chest, 140, 534-542. doi:10.1378/chest.10-2223
[37]	Sert-Kuniyoshi, F.H., Squires, R.W., Korenfeld, Y.K., Somers, V.K., Pusalavidyasagar, S., Caples, S.M., Johnson, L.L., Thomas, R.J. and Lopez-Jimenez, F. (2011) Screening for obstructive sleep apnea in early outpatient cardiac rehabilitation: Feasibility and results. Sleep Medicine, 12, 924-927. doi:10.1016/j.sleep.2010.11.014
[38]	Lurie, A. (2011) Cardiovascular disorders associated with obstructive sleep apnea. Advances in Cardiology, 46, 197-266.
[39]	Pronzato, C. (2010) Chronic obstructive pulmonary disease and obstructive sleep apnea. Association, consequences and treatment. Monaldi Archives for Chest Disease, 73, 155-161.
[40]	Chen, Y.H., Kang, J.H., Lin, C.C., Wang, I.T., Keller, J.J. and Lin, H.C. (2011) Obstructive sleep apnea and the risk of adverse pregnancy outcomes. American Journal of Obstetrics & Gynecology, 206, 136.e1-136.e5.
[41]	Cooke, J.R., Ayalon, L., Palmer, B.W., Loredo, J.S., Corey-Bloom, J., Natarajan, L., Liu, L. and Ancoli-Israel, S. (2009) Sustained use of CPAP slows deterioration of cognition, sleep, and mood in patients with Alzheimer’s disease and obstructive sleep apnea: A preliminary study. Journal of Clinical Sleep Medicine, 5, 305-309.
[42]	Youssef, N.A., Ege, M., Angly, S.S., Strauss, J.L. and Marx, C.E. (2011) Is obstructive sleep apnea associated with ADHD? Annals of Clinical Psychiatry, 23, 213-224.