Sleep Apnea in Elderly Adults with Chronic Insomnia
2012; Wiley; Volume: 60; Issue: 12 Linguagem: Inglês
10.1111/jgs.12006
ISSN1532-5415
AutoresKiyoka Kinugawa, Mohamed Doulazmi, C. Sebban, Sophie Schumm, Jean Mariani, Vi‐Huong Nguyen‐Michel,
Tópico(s)Sleep and Wakefulness Research
ResumoJournal of the American Geriatrics SocietyVolume 60, Issue 12 p. 2366-2368 Letters to the EditorFree Access Sleep Apnea in Elderly Adults with Chronic Insomnia Kiyoka Kinugawa MD, PhD, Kiyoka Kinugawa MD, PhD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, France Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorMohamed Doulazmi PhD, Mohamed Doulazmi PhD Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorClaude Sebban MD, Claude Sebban MD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, France Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorSophie Schumm PhD, Sophie Schumm PhD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, FranceSearch for more papers by this authorJean Mariani MD, PhD, Jean Mariani MD, PhD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, France Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorVi-Huong Nguyen-Michel MD, Vi-Huong Nguyen-Michel MD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, FranceSearch for more papers by this author Kiyoka Kinugawa MD, PhD, Kiyoka Kinugawa MD, PhD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, France Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorMohamed Doulazmi PhD, Mohamed Doulazmi PhD Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorClaude Sebban MD, Claude Sebban MD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, France Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorSophie Schumm PhD, Sophie Schumm PhD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, FranceSearch for more papers by this authorJean Mariani MD, PhD, Jean Mariani MD, PhD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, France Université Pierre-et-Marie-Curie, University of Paris 6, UMR 7102 Neurobiologie des Processus Adaptatifs, Centre National de la Recherche Scientifique, Paris, FranceSearch for more papers by this authorVi-Huong Nguyen-Michel MD, Vi-Huong Nguyen-Michel MD Functional Exploration Unit, Consultation and Investigation Center for the Elderly, Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, FranceSearch for more papers by this author First published: 11 December 2012 https://doi.org/10.1111/jgs.12006Citations: 6AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat To the Editor: Insomnia and sleep apnea syndrome (SAS) are common in elderly adults.1, 2 SAS may generate insomnia complaints by repeatedly interrupting sleep, altering sleep quality, and producing perceptions of unrestored sleep. Only a few studies have focused on the characteristics of SAS in elderly adults with insomnia.3, 4 Polysomnography (PSG) is the criterion standard for SAS diagnosis but is not systematically indicated in individuals with insomnia, yet identifying SAS in people with insomnia is crucial because the therapeutic management of SAS is different from that of insomnia. Over a period of 29 months, outpatients aged 60 and older who consulted with physicians specializing in sleep for insomnia complaints—difficulty initiating or maintaining sleep, waking up too early, experiencing nonrestorative or poor quality sleep despite adequate opportunity and circumstances for sleep, and experiencing daytime functional consequences,5 at least three times per week for at least 6 months—were selected. The prevalence, characteristics, and predictors of SAS were examined in these individuals using clinical interviews, overnight ambulatory PSG (including 6 electroencephalogram (EEG) leads, electrooculogram, chin and leg electromyogram, nasal canula, thoracic and abdominal bands and pulse oximeter) and multiple sleep latency tests (MSLTs). Apnea was defined as a complete absence of nasal airflow for at least 10 seconds. Hypopnea was defined as an event lasting at least 10 seconds with a 50% or greater decrease in the airflow or a 30% or greater decrease in airflow accompanied by a 3% or greater decrease in oxyhemoglobin saturation or an EEG arousal. Flow limitation was a decrease of 30% or less in the form of classic flattening of the airflow limb for at least two consecutive breaths, lasting 10 s or longer and ending in an EEG arousal. SAS was defined as an apnea, hypopnea, flow limitation index (AHI) of 15/hour or greater. Individuals with night time sleep recorded less than 3 hours were excluded. The Charles Foix Hospital institutional review board approved this study. Multilinear regression analyses were tested using stepwise backward selection of the explicative variables. Of 64 participants included (mean age 72, range 60−91; 40 women), 44 (68.7%) had SAS (mean AHI = 33.6 ± 13.9/hour), and 41 (64%) were taking a benzodiazepine or a benzodiazepine receptor agonist (BRA). Fourteen participants did not report any of three cardinal symptoms of SAS (snoring, observed apnea, and excessive daytime sleepiness), but six had an AHI of 15/hour or more. The SAS group had more participants who reported snoring symptoms (P = .03), had higher (P = .002) but still moderate body mass indices (BMI), and had a shorter (P = .006) but subnormal MSLT value (Table 1). Logistic analysis showed that SAS was positively associated with BMI (odds ratio (OR) = 1.33; P = .01) and negatively associated with MSLT value (OR = 0.87; P = .03). Multiple regression analysis showed that age (P = .03), BMI (P = .01), sleep onset latency (P = .049), snoring (P = .03), and BRA use (P = .004) were positively correlated, whereas MSLT values (P < .001) were negatively correlated with SAS severity. Table 1. Comparison of Individuals with Insomnia with and without Sleep Apnea Syndrome (SAS) Characteristic SAS, n = 44 No SAS, n = 20 P-Value Age, mean ± SD 72.9 ± 8.9 70.1 ± 7.8 .23aa Student t-test. Male/Female, n 18/26 6/14 .40bb Pearson chi-square test. Body mass index, kg/m2, median (IQR) 27.4 (23.4–31) 24.2 (22.9–25.3) .002cc Mann-Whitney test. Mini Mental State Examination score, median (IQR) 28 (24–29) 28 (26–29.2) .58cc Mann-Whitney test. Insomnia duration, years, mean ± SD 15.8 ± 14.5 12.9 ± 8.6 .83cc Mann-Whitney test. Difficulty initiating sleep, n/N 36/44 14/20 .29bb Pearson chi-square test. Difficulty maintaining sleep, n/N 36/44 18/20 .40bb Pearson chi-square test. Waking up too early, n/N 19/44 9/20 .89bb Pearson chi-square test. Snoring, n/N 34/43 10/19 .03bb Pearson chi-square test. Excessive daytime sleepiness, n/N 12/43 4/19 .57bb Pearson chi-square test. Observed apnea, n/N 13/43 4/19 .45bb Pearson chi-square test. Subjective sleep duration, minutes, median (IQR) (min, median (IQR) 300 (240–360) 300 (180–360) .57cc Mann-Whitney test. Benzodiazepine use, n/N 16/44 19/20 .51bb Pearson chi-square test. Benzodiazepine receptor agonist use, n/N 14/44 3/20 .12bb Pearson chi-square test. Epworth Sleepiness Scale score, mean ± SD 6.1 ± 4.4 6.2 ± 3.8 .71cc Mann-Whitney test. Geriatric Depression Scale score, mean ± SD 9.2 ± 6.4 11.8 ± 7.7 .20aa Student t-test. Multiple sleep latency test, minutes, mean ± SD 9.7 ± 6.1 14.2 ± 4.9 .006aa Student t-test. Total sleep time, minutes, median (IQR) 377.5 (311.5–443.7) 353.5 (318.7–417.7) .19aa Student t-test. Sleep onset latency, minutes, median (IQR) 9.5 (6.7–22.2) 16.5 (4–21.2) .94cc Mann-Whitney test. Sleep efficiency,%, median (IQR) 74.5 (62–81.1) 73.3 (65.7–84.5) .86cc Mann-Whitney test. Waking after sleep onset, minutes, median (IQR) 112.5 (72.5–150.5) 104 (52–142.2) .34cc Mann-Whitney test. Subjective sleep parameters were estimated based on a clinical interview. Objective sleep parameters were measured according to polysomnography. a Student t-test. b Pearson chi-square test. c Mann-Whitney test. SD = standard deviation; IQR = interquartile range. A higher prevalence of SAS (68.7%) was found in elderly adults with insomnia than previously reported (29%),3, 4 although the populations were different, and the current study included flow limitations associated with arousal in the AHI, which allowed for a better estimation of SAS according to recommendation.6 Subjective daytime sleepiness evaluation according to clinical interview and Epworth Sleepiness Scale indicated similar results in participants with and without SAS, which is consistent with other studies.3, 7 The only previous study using objective evaluation according to MSLT in elderly adults with insomnia reported similar result in two groups.3 The current study found a smaller MSLT mean value in the group with SAS (9.7 minutes) than in that without (14.2 minutes), which was nevertheless within normal range value (> 8 minutes),8 and showed that the MSLT value predicted SAS and SAS severity. Even at subnormal value, it may thus be suggestive of SAS in elderly adults with insomnia. Elderly adults with SAS may not necessarily be obese, but BMI predicts SAS in elderly adults.9 It was also found that BMI predicted SAS severity. BRA use predicted SAS severity, whereas benzodiazepine use did not. BRAs are always indicated as hypnotics and prescribed in the evening, producing their maximal effects during the night, whereas benzodiazepines, with longer half-lives, may have different indications and be prescribed differently. SAS is more frequent in elderly adults with insomnia than previously believed. The current study confirms the results of previous studies that clinical examination and interviews are not sufficient to exclude SAS.4 Some clinical and paraclinical characteristics were suggestive of SAS but difficult to recognize in this population. PSG yields important diagnostic information in these individuals. Using PSG routinely in elderly adults with insomnia is useful, and indications for PSG should be less restrictive in this population than the current guidelines recommend.4, 7, 10 Acknowledgments We thank all the technicians for performing PSG (Valérie Pichon, Catherine Tricot, and Philippe Noël). Conflict of Interest: The authors have no conflict of interest to declare in relation to this work. Author Contributions: KK, VNM: study concept and design, acquisition of participants and data, analysis and interpretation of data, and writing the manuscript. MD: statistical analysis and interpretation of data. JM, CS, SS: preparation of manuscript. Sponsor's Role: None. References 1Foley DJ, Monjan AA, Brown SL et al. Sleep complaints among elderly persons: An epidemiologic study of three communities. Sleep 1995; 18: 425– 432. CrossrefCASPubMedWeb of Science®Google Scholar 2Ancoli-Israel S, Kripke DF, Klauber MR et al. Sleep-disordered breathing in community-dwelling elderly. 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