Who Should Be Screened For Sleep Apnea? The Answer Is Not Always Obvious

By February 24, 2017Blog Post
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By Rebecca Nebel, PhD, Assistant Director of Scientific Programs at SWHR

There is insufficient current evidence to assess the benefits and harms of screening for obstructive sleep apnea in asymptomatic adults [1], according to an assessment recently released by the United States Preventative Services Task Force (USPSTF). USPSTF, an independent, volunteer panel of national experts in prevention and evidence-based medicine, makes recommendations about the effectiveness of specific preventive care services for patients. USPSTF’s finding also applies to individuals with sleep apnea who are not aware of their symptoms or do not report symptoms as a concern. This is troubling, as it may impede primary care providers from discussing the signs and symptoms of obstructive sleep apnea (which we will refer to as sleep apnea) with their patients.

Sleep apnea affects 34 percent of men and 17 percent of women [2]. It not only increases the risk for a number of cardiovascular and metabolic diseases (e.g. heart disease, stroke, and diabetes), but also for motor vehicle crashes and mortality [1].

Data shows that the delay between development of symptoms and a sleep apnea diagnosis can be upwards of 7 to 10 years [3, 4]. This delay occurs despite many visits to primary care providers [3]. Many individuals with sleep apnea do not report “textbook” symptoms of sleep apnea, which include excessive daytime sleepiness and snoring. For example, one study found that over one-third of patients with moderate or severe sleep apnea reported excessive daytime sleepiness [5, 6]. This suggests that many individuals with sleep apnea would not necessarily report “textbook” symptoms to their primary care providers. In light of USPSTF’s recent statement about screening for sleep apnea, it is unlikely that these individuals would be viewed as candidates for such an evaluation.

There is also a need to address sex and gender differences in sleep apnea symptoms. Sleep apnea is a widely under-recognized disorder, particularly in women. Studies estimate over 90 percent of women with sleep apnea are not diagnosed [7]. One reason for this under-diagnosis is that many women do not have “textbook” symptoms and are more likely to report non-“textbook” symptoms such as fatigue, insomnia, and mood disturbances [8, 9]. Healthcare providers may not recognize these signs of sleep apnea, which can lead to misdiagnosis and mistreatment. Consequently, it is important to raise awareness of the differences in sleep apnea symptoms between women and men. USPSTF does not address the explicit need for improving recognition (and ultimately prevention and treatment of sleep apnea) in women, despite evidence that women are at high risk for sleep apnea related health problems, such as cognitive impairment [10] and heart failure [11]. Healthcare providers may continue to miss proper diagnosis in women unless they take sex and gender differences in sleep apnea symptoms into account during primary care visits.

Pregnant women are explicitly excluded from USPSTF’s recommendation. Pregnancy is often a time where sleep apnea is unmasked or becomes exacerbated [12]. Sleep apnea during pregnancy increases the risk for adverse outcomes for both mother and baby, including preeclampsia, gestational diabetes, preterm birth, NICU admission, and maternal death [12, 13].

Because current screening tools may not be sensitive to measuring how sleep apnea presents itself in pregnant women and women in general, it is important that healthcare providers be vigilant towards non-“textbook” symptoms in women across their lifespan. It is crucial for primary care providers to ascertain a patient’s medical history, including sleep apnea symptoms, and to recognize that “textbook” symptoms as well as non-“textbook” symptoms (insomnia, fatigue, mood disturbances) all may be indicators of sleep apnea.

The Society for Women’s Health Research Interdisciplinary Network on Sleep is committed to promoting awareness of sex and gender differences of sleep and circadian rhythms across the lifespan, and the impact they have on health and well-being. Learn more about the Sleep Network here.

References

  1. US Preventive Services Task Force., Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement. JAMA, 2017.
  2. Peppard, P.E., et al., Increased prevalence of sleep-disordered breathing in adults. American journal of epidemiology, 2013. 177(9): p. 1006-1014.
  3. Rahaghi, F. and R.C. Basner, Delayed diagnosis of obstructive sleep apnea: don’t ask, don’t tell. Sleep and Breathing, 1999. 3(04): p. 119-124.
  4. Redline, S., et al., Patient Partnerships Transforming Sleep Medicine Research and Clinical Care: Perspectives from the Sleep Apnea Patient-Centered Outcomes Network. Journal of clinical sleep medicine, 2015. 12(7): p. 1053-1058.
  5. Carter, G.S., Screening for Improvement of Health Outcomes in Asymptomatic Obstructive Sleep Apnea. JAMA neurology, 2017.
  6. Young, T., et al., Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep, 2008. 31(8): p. 1071-1078.
  7. Young, T., et al., Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep, 1997. 20(9): p. 705-706.
  8. Kump, K., et al., Assessment of the validity and utility of a sleep-symptom questionnaire. American journal of respiratory and critical care medicine, 1994. 150(3): p. 735-741.
  9. Valipour, A., et al., Gender-related differences in symptoms of patients with suspected breathing disorders in sleep: a clinical population study using the sleep disorders questionnaire. Sleep, 2007. 30(3): p. 312.
  10. Yaffe, K., et al., Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA, 2011. 306(6): p. 613-9.
  11. Roca, G.Q., et al., Sex-Specific Association of Sleep Apnea Severity With Subclinical Myocardial Injury, Ventricular Hypertrophy, and Heart Failure Risk in a Community-Dwelling Cohort: The Atherosclerosis Risk in Communities-Sleep Heart Health Study. Circulation, 2015. 132(14): p. 1329-37.
  12. Louis, J.M., et al., Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep, 2014. 37(5): p. 843.
  13. Louis, J., et al., Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women. Obstetrics and gynecology, 2012. 120(5).

 

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