Primary Care: Is It the Setting to Address Sleep Disorders?

Abstract

lation than in the general population, and very likely at higher levels of severity. Why might this be true? One reason is the nature of medical practice, where most encounters (> 85%) are for chronic and acute disease. 1 This results in an enriched profile for risk factors. For example, in the Cleveland cohort studied with the Berlin Questionnaire (see Appendix), 50% of a consecutively studied primary care patient population was obese and/or hypertensive. 2 Moreover, such patients were more likely to visit their family doctor than healthy adults.Prior studies in primary care have emphasized a single sleep disorder. Several reports have emphasized insomnia in youthful 3-5 and geriatric populations. 6-7 Sochat and Ancoli-Israel 8 found 69% prevalence for insomnia in patients over 65 years of age. They suggest that the primary care population has a higher prevalence of insomnia than the general population because of concomitant psychiatric and medical illness.Stoohs et al. 9 showed a high prevalence of sleep disordered breathing in a sample of primary care patients. The high prevalence of sleep disordered breathing was confirmed in a larger sample by Netzer et al. 2 using the Berlin Questionnaire. Pediatricians first acknowledged the need for the family practitioner to recognize sleep disorders in the infants and children they cared for because parents often sought advice from their family doctor first before they went to a pediatrician or to one of the (rare) pediatric sleep specialists. [10][11][12] In 1993, the Wisconsin cohort study reported an obstructive sleep apnea population prevalence of 24% in adult men and 9% in adult women 13 , with 2 to 4% showing clear symptoms. Although obstructive sleep apnea was already identified as a public health problem, the Wisconsin cohort results removed all doubt of the high prevalence of this major sleep disorder. This is a difficult question because it is potentially embarrassing to show that quite unbeknownst to the physician, a river of sleep disorders is flowing through a clinic.Although largely ignored in the early evolution of sleep medicine, interest in the need to improve recognition of sleep disorders in primary care patient populations is beginning to increase. The study by Kushida et al. in this issue of Sleep and Breathing presents data strongly supporting a very high prevalence of sleep disorders in the primary care setting. These authors report that 60.1% of patients interviewed consecutively for one year presented unambiguous symptomatology at levels of severity deemed highly likely to be confirmed by polysomnographic testing. On the other hand, nearly all the symptomatic patients in the study of Kushida et al. had not had a prior sleep diagnosis. Moreover, in the entire scientific/clinical literature there is no evidence whatsoever that more than a tiny fraction of patients afflicted with sleep disorders receive specific diagnoses and the appropriate, beneficial treatment from primary physicians. This deplorable state of affairs co-exists with an enormous...

Prevalence of symptoms and risk of sleep apnea in Dubai, UAE

“…Primary care has a central role for recognizing cases of OSAS in the community 4. Patients attending primary care clinics tend to have a higher risk for OSAS because these patients often have chronic illnesses that are associated with OSAS.…”

Underdiagnosis of Sleep Apnea Syndrome in U.S. Communities

“…In other studies of primary care populations, the estimated prevalence of diagnosed OSAHS is approximately 0.3% in contrast to the 20 to 30 times greater community prevalence of those with persistent sleepiness and snoring or those regarded as being at high risk for moderate to severe illness. 3 The Sleep Heart Health Study (SHHS) is a multicenter longitudinal study of the relationship of sleep-disordered breathing and cardiovascular diseases in nine community-based parent cohorts across the United States. Details of the rationale, study design, and primary hypotheses of the SHHS have been published.…”

Is Pulmonary Hypertension Common in Uncomplicated OSA?

“…One usually assumes that this occurs as a result of an enrichment of risk factors including co-morbidity and the length of illness that results in referral to a specialty clinic. Although recognition of sleep apnea is rather uncommon in primary care [18], there are papers that suggest that OSA can be recognized in primary care offices by the presence of new-onset pre-tibial edema and/ or unexplained pulmonary hypertension [19,20]. What is unresolved in these studies as well as in the current literature is whether or not pulmonary hypertension by itself can be the sole presenting feature of OSAHS or is captured by current recognition strategies that focus on presenting symptoms like snoring and sleepiness rather than abnormal physical or laboratory findings.…”