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

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 been previously recognized. 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 scientific literature documenting the morbidity and mortality consequences of these disorders. Even as we embark upon the third millennium, the continuing failure to recognize sleep disorders in primary care medical practice constitutes a major personal and public health crisis that absolutely must be addressed. We will herein review some of the problems, issues, and possibilities involved in meeting this challenge.

Issue #1-Can We Consider the Very High Prevalence of Sleep Disorders in Primary Care Populations an Established Fact?

All types of sleep disorders probably exist in a higher prevalence among the primary care patient population 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 younger[3] [4] [5] and geriatric populations.[6] [7] Sochat and Ancoli-Israel[8] found 69% prevalence for insomnia in older patients. 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. Already identified as a public health problem, the Wisconsin cohort results removed all doubt of the high prevalence of a major sleep disorder.

REFERENCES

• 1 Stange K C, Zyzanski S J, Jaen C R. Illuminating the "black box." A description of 4454 patient visits to 138 family physicians.  J Fam Med . 1998;  46 337-389
• 2 Netzer N C, Stoohs R, Netzer C M, Clark K, Strohl K P. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.  Ann Intern Med . 1999;  131 485-491
• 3 Radecki S E, Brunton S A. Management of insomnia in office-based practice. National prevalence and therapeutic patterns.  Arch Fam Med . 1993;  2 1129-1134
• 4 Rakel R E. Insomnia: Concerns of the family physician.  J Fam Pract . 1993;  36 551-581
• 5 Mata Ruiz I, Ortiz Lobo A, Hernandez Monsalve M, Gervas J. Insomnia in general practice: The opinion of the patient and the professional.  Aten Primaria . 1995;  16 271-274
• 6 Lemkau J P, Martin A M, Olsen C G. Informational yield of a comprehensive geriatric home assessment.  Fam Pract Res J . 1993;  13 275-281
• 7 Hohagen F, Kappler C, Schramm E, Rink K, Weyerer S, Riemann D, Berger M. Prevalence of insomnia in elderly general practice attenders and the current treatment modalities.  Acta Psychiatr Scand . 1994;  90 102-108
• 8 Shochat T, Umphress J, Israel A G, Ancoli-Israel S. Insomnia in primary care patients.  Sleep . 1999;  22(Suppl 2) 359-365
• 9 Stoohs R A, Barger K, Dement W C. Sleep disordered breathing in primary care medicine.  Sleep and Breathing . 1997;  1 11-22
• 10 Adair R H, Bauchner H. Sleep problems in childhood.  Curr Probl Pediatr . 1993;  23 147-170
• 11 Brayden R M, Poole S R. Common behavioral problems in infants and children.  Prim Care . 1995;  22 81-97
• 12 Hudak B B, O' Donnell J, Mazyrka N. Infant sleep position: Pediatricians advice to parents.  Pediatrics . 1995;  95 55-58
• 13 Young T, Palta M, Dempsey J. The occurence of sleep disordered breathing among middle aged adults.  N Engl J Med . 1993;  328 1230-1235
• 14 Gonzalez-Luque F J, Fuertes A, Gonzalez-Luque J C. A new cause for primary care consultation: Nocturnal snoring.  Aten-Primaria . 1995;  16 49-54
• 15 Hoelsboer-Trachsler E, Kocher R. Sleep disorders: Diagnosis and treatment.  Schweiz Med Wochenschr . 1995;  125 2346-2352
• 16 Meissner H H, Riemer A, Santiago S M. Failure of physician documentation of sleep complaints in hospitalized patients.  West J Med . 1998;  169 146-149
• 17 Walsh J K, Dement W C. Sleep disturbance in primary care patients with fatigue.  J Gen Intern Med . 1993;  8 168
• 18 Ward M H, DeLisle H, Shores J H, Slocum P C, Foresman B H. Chronic fatigue complaints in primary care: Incidence and diagnostic patterns.  J Am Osteopath Assoc . 1996;  96 34-46
• 19 Stoliar L, Shvartzman P, Horenstein I. Nocturnal penile tumescence and rigidity monitor-use in a family practice.  Isr J Med Sci . 1995;  31 359-364
• 20 Kramer N R, Cook T E, Carlisle C C, Corwin R W, Millman R P. The role of the primary care physician in recognizing sleep apnea.  Arch Intern Med . 1999;  159 965-968
• 21 Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.  Sleep . 1997;  20(9) 705-706
• 22 Partinen M. Ischaemic stroke, snoring and obstructive sleep apnea.  J Sleep Res . 1995;  4 156-159
• 23 Dyken M E, Somers V K, Yamada T, Ren Z, Zimmermann M B. Investigating the relationship between stroke and obstructive sleep apnea.  Stroke . 1996;  27 401-407
• 24 Bassetti C, Aldrich M S. Sleep apnea in acute cerebrovascular diseases: Final report on 128 patients.  Sleep . 1999;  22(2) 217-223
• 25 Ronald J, Delaive K, Roos L, Manfreda J, Bahammam A, Kryger M H. Health care utilization in the 10 years prior to diagnosis in obstructive sleep apnea syndrome patients.  Sleep . 1999;  22(2) 225-229
• 26 Bahammam A, Delaive K, Ronald J, Manfreda J, Roos L, Kryger M H. Health care utilization in males with obstructive sleep apnea syndrome two years after diagnosis and treatment.  Sleep . 1999;  22(6) 740-747
• 27 National Heart, Lung, and Blood Institute Working Group on Insomnia. Insomnia: Assessment and management in primary care.  Am Fam Physician . 1999;  59 3029-3038
• 28 Green P M, Stillman M J. Narcolepsy. Signs, symptoms, differential diagnosis and management.  Arch Fam Med . 1998;  7 472-478
• 29 Canellas Dols F, Ochogavia Canaves J, Llobera Canaves J. Sleep disorders and the consumption of hypnotics on the island of Mallorca.  Rev Clin Esp . 1998;  198 719-725
• 30 Chesson Jr L A, Wise M, Davilla D. Practice parameters for the treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Report. Standards of Practice Committee of the American Academy of Sleep Medicine.  Sleep . 1999;  22 961-968
• 31 Stewart D, Abbey S, Meana M, Boydell K M. What makes a woman tired?.  J Womens Health . 1998;  7 69-76
• 32 Ang D C, Calabrese L H. A common-sense approach to chronic fatigue in primary care.  Cleve Clin J Med . 1999;  66 343-350
• 33 National Heart, Lung, and Blood Institute Working Group on Sleep Apnea. Sleep apnea: is your patient at risk?.  Am Fam Physician . 1996;  53 247-253
• 34 Davidson T M. Sleep studies and primary care.  West J Med . 1997;  167 426
• 35 Teran Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander.  N Engl J Med . 1999;  340 847-851
• 36 Johns M V. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale.  Sleep . 1991;  14 540-545
• 37 Floyd J A. Sleep promotion in adults.  Annu Rev Nurs Res . 1999;  17 27-56
• 38 Strohl K P, Haponik E E, Sateia M J. The need for a knowledge system in sleep and chronobiology.  Academic Medicine (in press).
• 39 Herold G. Innere Medizin - 1999. Köln Herold Eigenverlag 1999
• 40 Ball E M, Simon Jr D R, Tall A A, Banks M B, Nino-Murcia G, Dement W C. Diagnosis and treatment of sleep apnea within the community. The Walla Walla Project.  Arch Intern Med . 1997;  157 419-424
• 41 Simon R D, Ball E M, Falcon J C. Sleep disorders in a rural community: Follow-up of the Walla Walla project.  Sleep . 1999;  22(S) 239