FROM THE CLINICAL KNOWLEDGE CENTER
Dozing at the Doctor's Office? Wake Up to the Problem

by Michelle Ostrander, PhD

Sleep-wake problems impact a large segment of the American population—current estimates suggest that 50 to 70 million Americans of all ages are affected by sleep-wake disturbances. These problems have far-reaching societal consequences, as they are associated with increased risk of traffic accidents, decrements in work performance, impaired interpersonal relationships, and increased health care utilization. Medical comorbidities are common in patients with primary sleep-wake disorders, such as obstructive sleep apnea (OSA). Epidemiologic research indicates that untreated OSA is associated with increased risk for hypertension, stroke, cardiovascular disease, and type 2 diabetes. In addition, laboratory studies suggest that sleep deprivation is associated with enhanced pain sensitivity, and alterations in glucose tolerance and insulin sensitivity that are consistent with an increased risk for diabetes. Despite the major impact of sleep-wake problems at the societal and individual level, little is known about the scope of these problems at the primary care level, the front-line of the health-care system.

Until recently, annual telephone polls by the National Sleep Foundation (NSF) provided the only insight into the prevalence of sleep-wake disorders/problems in the US, the impact of sleep-wake disorders/problems on daily activities, and current attitudes regarding sleep-related issues. According to the 2005 NSF Sleep Poll, 75% of respondents report having a symptom of a sleep-wake problem at least a few nights per week within the past year. While these data are intriguing and useful, they do not provide insight into the prevalence and nature of sleep-wake disorders within the primary care population.

A recent study published in the Journal of the American Board of Family Medicine investigated this issue. Researchers screened adult patients at five family practice offices for sleep-wake disorders and sought to determine which demographic and health status factors were associated with these disorders.

Nearly three thousand adult patients (N = 2963) were approached to complete a four-page questionnaire that included items on excessive sleepiness, insomnia, obstructive sleep apnea (OSA), and restless leg syndrome. Of those approached, 1935 patients were enrolled in the study (67.7% female, mean age = 50.1 years). Symptoms of excessive sleepiness were prevalent in a large proportion of the population; 55.4% of participants reported feeling sleepy at least once per week doing daily activities and 37.1% of participants reported dozing off at least once per week doing daily activities. Unpleasant, tingling, creeping or restless feelings in the legs, suggestive of restless leg syndrome (RLS), were reported by over one-quarter of respondents (28.2%) at least one time per week. Symptoms of OSA, such as snoring loudly or gasping/breathing pauses during sleep, were reported by 13.6% and 33.0% of participants, respectively. Lastly, over one-third of participants reported waking more than 3 times per night within a one-week period, suggestive of insomnia. The frequency of sleep-wake symptoms varied significantly by age. Patients less than 65 years of age were more likely to report symptoms consistent with OSA whereas patients over 65 years of age were more likely to report daytime dozing.

Several demographic variables were significantly associated with sleep-wake symptoms. Older patients were more likely to report dozing during the day (OR, 1.44) but less likely to report symptoms of OSA (snoring: OR, 0.74; gasping during sleep: OR, 0.58) or insomnia (OR, 0.79). Women were more likely to report symptoms consistent with insomnia (OR, 1.28) but less likely to experience snoring (OR, 0.54) or gasping during sleep (OR, 0.69). Racial differences in the likelihood of sleep-wake symptoms were also observed—Latinos were less likely than whites to report sleepiness or dozing during daily activities (OR, 0.53 and 0.49, respectively), symptoms consistent with RLS (OR, 0.46), and snoring (OR, 0.53). Married participants were more likely to report snoring (OR, 1.52) and less likely to report insomnia (0.79) after adjusting for age, sex, and race.

Poor self-ratings on physical and mental health were associated with significantly higher risk for all sleep-wake problems. In particular, participants with depression, hypertension, and pain syndromes (chronic back pain, arthritis, joint pain or stiffness) exhibited a significantly greater risk of all sleep-wake complaints. Patients with a body mass index ≥ 30 kg/m² were twice as likely to report snoring (OR, 2.18) and gasping during sleep (OR, 2.20), as well as symptoms consistent with RLS (OR, 1.23) and insomnia (OR, 1.32). Patients with heart disease had an elevated risk of symptoms suggestive of RLS (OR, 2.06) and insomnia (OR, 1.57), and were more likely to report sleepiness or dozing during daily activities (OR, 1.45 and 1.81, respectively). Patients with lung disease were at increased risk for sleepiness during daily activities (OR, 1.79) and snoring (OR, 1.49), as well as symptoms of insomnia (OR, 2.34), OSA (OR, 2.94), and RLS (OR, 2.24). Patients with cancer reported an increased risk for symptoms consistent with insomnia (OR, 1.48). Smokers exhibited an elevated risk of sleepiness during daily activities (OR, 1.31) and symptoms suggestive of insomnia (OR, 1.48), RLS (OR, 1.87), and sleep apnea (OR, 1.78).

Findings from this study indicate that complaints of sleep and wakefulness are highly prevalent in the primary care setting and associated with a significant negative impact on health. Given this, primary care practitioners should actively screen patients for sleep-wake problems, and investigate positive responses with appropriate screening tools and laboratory tests.

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