Determinants of subjective sleepiness in suspected obstructive sleep apnoea
IOANNIS KOUTSOURELAKIS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorELENI PERRAKI
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorANASTASIOS BONAKIS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorEMMANOUIL VAGIAKIS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorCHARIS ROUSSOS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorSPYROS ZAKYNTHINOS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorIOANNIS KOUTSOURELAKIS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorELENI PERRAKI
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorANASTASIOS BONAKIS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorEMMANOUIL VAGIAKIS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorCHARIS ROUSSOS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorSPYROS ZAKYNTHINOS
Center of Sleep Disorders, Department of Critical Care and Pulmonary Services, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
Search for more papers by this authorSummary
Although daytime sleepiness is commonly associated with obstructive sleep apnoea (OSA), the relationship between OSA severity and subjective sleepiness has been documented elusive. This study aimed to identify clinical and polysomnographic determinants of subjective sleepiness among patients suspected of having OSA. A sleep clinic-based sample of 915 patients was interviewed with a structured questionnaire and underwent diagnostic overnight polysomnography. Subjective sleepiness was quantified by Epworth Sleepiness Scale (ESS). Excessive daytime sleepiness (defined as ESS score > 10) was present in 38.8% of patients. In multiple linear regression analysis, respiratory disturbance index [RDI; used to define (whenever RDI was >5) and quantify OSA], depression and diabetes were the most important determinants of ESS score accounting for 17%, 11% and 6% of its variability respectively. Chronic obstructive pulmonary disease (COPD), stroke, heart disease, alcohol use and body mass index were less important determinants of ESS score explaining 1–3% of its variability. In conclusion, OSA should not be considered the sole potential cause of increased subjective sleepiness in patients suspected of having OSA. Primarily depression and diabetes, but also COPD, stroke, heart disease, alcohol use and increased body mass index may contribute to increased subjective sleepiness.
Supporting Information
Table S1 Symptoms of the total study population, as well as comparison of these symptoms between subjects with and without excessive daytime sleepiness.
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References
- American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep, 1999, 22: 667–689.
- American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care, 2005, 28: S37–S42.
- Asplund, R. Daytime sleepiness and napping amongst the elderly in relation to somatic health and medical treatment. J. Int. Med., 1996, 239: 261–267.
- Baldwin, C., Griffith, K., Nieto, F., O’Connor, G. T., Walsleben, J. A. and Redline, S. The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep, 2001, 24: 96–105.
- Barbe, F., Mayoralas, L., Duran, J., Masa, J. F., Maimó, A., Montserrat, J. M., Monasterio, C., Bosch, M., Ladaria, A., Rubio, M., Rubio, R., Medinas, M., Hernandez, L., Vidal, S., Douglas, N. J. and Agustí, A. G. Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness. Ann. Intern. Med., 2001, 134: 1015–1023.
- Bixler, E., Vgontzas, A., Lin, H., Calhoun, S. L., Vela-Bueno, A. and Kales, A. Excessive daytime sleepiness in a general population sample: the role of sleep apnea, age, obesity, diabetes and depression. J. Clin. Endocrinol. Metab., 2005, 90: 4510–4515.
- Breslin, E., Van Der Schans, C., Breukink, S., Meek, P., Mercer, K., Volz, W. and Louie, S. Perception of fatigue and quality of life in patients with COPD. Chest, 1998, 114: 958–964.
-
Chervin, R. and
Aldrich, M.
The Epworth Sleepiness Scale may not reflect objective measures of sleepiness or sleep apnoea.
Neurology, 1999, 51: 125–131.
10.1212/WNL.52.1.125 Google Scholar
- Davies, D., Rodgers, H., Walshaw, D., James, O. F. and Gibson, G. J. Snoring, daytime sleepiness and stroke: a case–control study of first-ever stroke. J. Sleep Res., 2003, 12: 313–318.
- Elwood, P., Hack, M., Pickering, J., Hughes, J. and Gallacher, J. Sleep disturbance, stroke, and heart disease events: evidence from the Caerphilly cohort. J. Epidemiol. Community Health, 2006, 60: 69–73.
- Feinberg, I. Untreated type 2 diabetes as a cause of daytime somnolence. Sleep, 1993, 16: 82.
- Francis, G. S., Tang, H. W. and Sonnenblick, E. H.. Pathophysiology of heart failure. In: V. Fuster, R. W. Alexander and R. A. O’Rourke (Eds) Hurst’s The Heart, 11th edn. McGraw-Hill Medical Publishing Division, New York, 2004: 697.
- Goncalves, M., Paiva, T., Ramos, T. and Guilleminault, C. Obstructive sleep apnea syndrome, sleepiness, and quality of life. Chest, 2004, 125: 2091–2096.
- Gottlieb, D., Whitney, C., Bonekat, W., Iber, C., James, G. D., Lebowitz, M., Nieto, F. J. and Rosenberg, C. E. Relation of sleepiness to the respiratory distress index: the Sleep Heart Health Study Research Group. Am. J. Respir. Crit. Care Med., 1999, 159: 502–507.
- Guilleminault, C. and Philip, P. Tiredness and somnolence despite initial treatment of obstructive sleep apnea syndrome (what to do when an OSAS patient stays hypersomnolent despite treatment). Sleep, 1996, 19: S117–S122.
- Guilleminault, C., Partinen, M., Quera-Salva, M. A., Hayes, B., Dement, W. C. and Nino-Murcia, G. Determinants of daytime sleepiness in obstructive sleep apnea. Chest, 1988, 94: 32–37.
- Johns, M. A new method for measuring sleepiness: The Epworth Sleepiness Scale. Sleep, 1991, 12: 540–545.
- Kapur, V., Baldwin, C., Resnick, H., Gottlieb, D. J. and Nieto, F. J. Sleepiness in patients with moderate to severe sleep-disordered breathing. Sleep, 2005, 28: 472–477.
- Klink, M. and Quan, S. F. Prevalence of reported sleep disturbances in a general adult population and their relationship to obstructive airways diseases. Chest, 1987, 91: 540–546.
- Koutsourelakis, I., Vagiakis, E., Roussos, C. and Zakynthinos, S. Obstructive sleep apnoea and oral breathing in patients free of nasal obstruction. Eur. Respir. J., 2006, 28: 1222–1228.
- Kushida, C., Littner, M., Morgenthaler, T., Alessi, C., Bailey, D., Coleman, J., Friedman, L., Hirshkowitz, M., Kapen, S., Kramer, M., Lee-Chiong, T., Loube, D., Owens, J., Pancer, J. and Wise, M. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep, 2005, 28: 499–521.
- Littner, M., Kushida, C., Wise, M., Davila, D. G., Morgenthaler, T., Lee-Chiong, T., Hirshkowitz, M., Daniel, L. L., Bailey, D., Berry, R. B., Kapen, S. and Kramer, M. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep, 2005, 28: 113–121.
- Mayers, A. and Baldwin, D. Antidepressants and their effect on sleep. Hum Psychopharmacol. Clin. Exp., 2005, 20: 533–559.
- Mediano, O., Barcelo, A., Peña, M., Gozal, D., Agustí, A. and Barbé, F. Daytime sleepiness and polysomnographic variables in sleep apnoea patients. Eur. Respir. J., 2007, 30: 110–113.
- Mitler, M., Carskadon, M., Czeisler, C., Dement, W. C., Dinges, D. F. and Graeber, R. C. Catastrophes, sleep, and public policy: consensus report. Sleep, 1988, 11: 100–109.
- Nguyen, A., Baltzan, M., Small, D., Wolkove, N., Guillon, S. and Palayew, M. Clinical reproducibility of the Epworth Sleepiness Scale. J. Clin. Sleep. Med., 2006, 2: 170–174.
- Pallesen, S., Nordhus, I., Omvik, S., Sivertsen, B., Tell, G. S. and Bjorvatn, B. Prevalence and risk factors of subjective sleepiness in the general adult population. Sleep, 2007, 30: 619–624.
- Pollak, C. P. How should the multiple sleep latency test be analyzed? Sleep, 1997, 20: 34–39.
- Punjabi, N., O’Hearn, D., Neubauer, D., Nieto, F. J., Schwartz, A. R., Smith, P. L. and Bandeen-Roche, K. Modeling hypersomnolence in sleep-disordered breathing: a novel approach using survival analysis. Am. J. Respir. Crit. Care Med., 1999, 159: 1703–1709.
- Robinson, G., Smith, D., Langford, B., Davies, R. J. and Stradling, J. R. CPAP does not reduce blood pressure in non-sleepy hypertensive OSA patients. Eur. Respir. J., 2006, 27: 1229–1235.
- Roehrs, T., Zwyghuizen-Doorenbos, A., Timms, V., Zorick, F. and Roth, T. Sleep extension, enhanced alertness and the sedating effects of ethanol. Pharmacol. Biochem. Behav., 1989, 34: 321–324.
- Roehrs, T., Zwyghuizen-Doorenbos, A., Knox, M., Moskowitz, H. and Roth, T. Sedating effects of ethanol and time of drinking. Alcohol. Clin. Exp. Res., 1992, 16: 553–557.
- Ruíz-Primo, E., Jurado, J., Solis, H., Maisterrena, J. A., Fernández-Guardiola, A. and Valverde, C. Polysomnographic effect of thyroid hormones primary myxedema. Electroencephalog. Clin. Neurophysiol., 1982, 53: 559–564.
- Sanders, M., Newman, A., Haggerty, C., Redline, S., Lebowitz, M., Samet, J., O’Connor, G. T., Punjabi, N. M. and Shahar, E. Sleep Heart Health Study. Sleep and sleep-disordered breathing in adults with predominantly mild obstructive airway disease. Am. J. Respir. Crit. Care Med., 2003, 167: 7–14.
- Santamaria, J., Iranzo, A., Ma Montserrat, J. and De Pablo, J. Persistent sleepiness in CPAP treated obstructive sleep apnea patients: evaluation and treatment. Sleep Med. Rev., 2007, 11: 195–207.
- Schwartz, D., Kohler, W. and Karatinos, G. Symptoms of depression in individuals with obstructive sleep apnea may be amenable to treatment with continuous positive airway pressure. Chest, 2005, 128: 1304–1309.
- Shafer, A. B. Meta-analysis of the factor structures of four depression questionnaires: Beck, CES-D, Hamilton, and Zung. J. Clin. Psychol., 2006, 62: 123–146.
- Spiegel, K., Leproult, R. and Van Cauter, E. Impact of sleep debt on metabolic and endocrine function. Lancet, 1999, 354: 1435–1439.
- Stahl, S., Zhang, L., Damatarca, C. and Grady, M. Brain circuits determine destiny in depression: a novel approach to the psychopharmacology of wakefulness, fatigue, and executive dysfunction in major depressive disorder. J. Clin. Psychiatry, 2003, 64: 6–17.
- Tachibana, N. and Taniguchi, M. Why do we continue to use Epworth Sleepiness Scale? Sleep Med., 2007, 8: 541–542.
- Tsara, V., Serasli, E., Amfilochiou, A., Constantinidis, T. and Christaki, P. Greek version of the Epworth sleepiness scale. Sleep Breath, 2004, 8: 91–95.
- Tzanakis, N., Anagnostopoulou, U., Filaditaki, V., Christaki, P. and Siafakas, N. COPD group of the Hellenic Thoracic Society. Prevalence of COPD in Greece. Chest, 2004, 125: 892–900.
-
Vaughn, B. and
D’Cruz, O..
Cardinal manifestations of sleep disorders. In: M. Kryger,
T. Roth and
W. Dement (Eds) Principles and Practice of Sleep Medicine, 4th edn. Elsevier Saunders, Philadelphia, PA, 2005: 594–601.
10.1016/B0-72-160797-7/50056-2 Google Scholar
- Vgontzas, A., Bixler, E., Tan, T., Kantner, D., Martin, L. F. and Kales, A. Obesity without sleep apnea is associated with daytime sleepiness. Arch. Intern. Med., 1998, 158: 1333–1337.
- Wessendorf, T., Teschler, H., Wang, H., Konietzko, N. and Thilmann, A. F. Sleep-disordered breathing among patients with first-ever stroke. J. Neurol., 2000, 247: 41–47.
- Whitney, C., Enright, P., Newman, A., Bonekat, W., Foley, D. and Quan, S. F. Correlates of daytime sleepiness in 4578 elderly persons: the Cardiovascular Health Study. Sleep, 1998, 21: 27–36.
- Zwyghuizen-Doorenbos, A., Roehrs, T., Lamphere, J., Zorick, F. and Roth, T. Increased daytime sleepiness enhances ethanol’s sedative effects. Neuropsychopharmacology, 1988, 1: 279–286.
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