PATTERN OF SLEEP DISORDERS AMONG ADULT PATIENTS PRESENTING AT THE FAMILY MEDICINE CLINIC OF OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITAL COMPLEX ILE IFE
Background: Sleep is an important physiologic phenomenon necessary for wellbeing, normal functioning, optimum intellectual activity and productivity. Abnormalities of sleep are associated with considerable morbidity and mortality. Sleep disordered breathing and chronic insomnias are independent risk factors for hypertension, excessive daytime sleepiness, industrial and vehicular accidents. There are limited data on the prevalence and patterns of sleep disorders in the Family Medicine settings in Nigeria. Studies on sleep patterns and disorders are necessary to provide information on the magnitude of the problem and highlighting the unique role of Family Physicians in managing patients with this problem.
Objectives: This study determined the prevalence and pattern of sleep disorders among patients presenting at the Family Medicine Clinic of the OAUTHC Ile-Ife and
identified the factors associated with sleep disorders.
Methodology: This was a cross sectional study involving 410 subjects from the Family Medicine Clinic, OAUTHC, Ile- Ife. Consenting subjects who met the inclusion criteria were recruited using systematic random sampling technique. Subjects were interviewed with the aid of a questionnaire containing items on socio-demographic characteristics, medical history, and sleep pattern enquiry. It also included items from the Pittsburgh sleep quality index and Epworth Sleepiness Scale. Blood pressure, neck circumference, weight and height were measured with body mass index calculated. Exhaled carbon monoxide level was determined for each subject using smoke analyser (Bedfont United Kingdom). Data was analysed using statistical package for social sciences (SPSS) version 18.
Results: Four hundred and ten subjects were recruited of which 284 (69.3%) were females. The overall mean age was 48.5+ 16.5years with individuals aged 45-64 years and above constituting the majority (38.2%). Three hundred and sixteen (77.1%) were Christians, while Yoruba was the dominant ethnic group, 91.2%. Majority, 124 (30.2%) had tertiary education while 256 (62.4%) earned less than N18, 000 monthly. Fifty six
(13.7%) and 35 (8.5%) consumed alcohol and smoked cigarette respectively. Hypertension was the commonest medical condition seen in 147 (35.8%) subjects. Two hundred and eighty two (69%) subjects had sleep disorders. Dysomnias was the commonest sleep disorder, seen in 230 (56.1%) subjects, of which insomnia constituted the majority (48.7%) followed by snoring (32.2%). Overall the commonest sleep problem was insomnia, with a prevalence of 27.3%. One fifth of the study population had a high risk of obstructive sleep apnoea.
Several factors including age group 45-64years, being separated, divorced and widowed, lack of education, chronic medical condition and quantity of exhaled carbon monoxide were associated with sleep disorders, p < 0.05. There was no association between sleep disorders and sex, religion, anthropometric characteristics, income, shift work and location of accommodation.
Multiple regression analysis showed that individuals who are 45 years and above had at least 2.3 times the risk of having sleep disorders compared with younger age groups. Similarly divorce/separation or widowhood was associated with a significant risk of sleep disorder compared with the never married (OR 2.9 and 3.3 respectively). The risk of sleep disorders among respondents living close to a church or mosque was almost twice those living away from a church or mosque, (OR 1.9). Those with chronic medical conditions and high level of exhaled CO had increased risk of sleep disorders,
OR 2.4 and 2.9 respectively, p < 0.05.
Conclusion: About seven out of every 10 patients presenting to the Family Medicine Clinic of OAUTHC had sleep disorders. Routine screening for sleep disorders is important for early detection and treatment.
TABLE OF CONTENTS
Title page i
Table of content vi
List of Table vii
List of Figures viii
List of Abbreviations ix
Chapter One: Introduction 4
Chapter Two: Literature review 11
Chapter Three: Methodology 41
Chapter Four: Results 48
Chapter Five: Discussion 62
Chapter Six: Conclusions and Recommendations 70
CHAPTER ONE INTRODUCTION
Sleep is an important physiologic phenomenon. It is necessary for wellbeing, normal functioning and survival throughout life.1 It is a state of heightened anabolic state, accentuating the growth and rejuvenation of the immune, nervous, skeletal and muscular systems. During sleep neurohormonal agents are released. These have been noted to be essential for optimum intellectual activity, enhancement of creativity and memory.2
In healthy people, sleep is physiologically regulated by the body’s circadian rhythm which causes an increase in sleepiness twice during a 24 hour period. This refers to the periods of early morning (12 am- 1 am) and mid afternoon (1 pm - 4 pm). In addition, the physiological need for sleep is increased by sleep loss and sleep disruptions. The need for sleep and the circadian rhythm interact to determine the level of sleepiness and alertness.3 People with disturbances of either of these sleep regulating mechanisms can exhibit sleep problems. Many sleep disorders compromise daily functioning and could be life - threatening either directly or indirectly as a result of sleep related accidents.4 Poor sleep impairs the quality of life.5 However, the seriousness of sleep disorders is poorly recognised by the general public and the clinical community.
Sleep is divided into two main phases: Rapid eye movement (REM) and Non- rapid eye movement (NREM). Each of these is associated with distinct patterns of central nervous system activity.2 NREM sleep is divided into three stages NI, N2 and N3. Sleep begins with transitions from wakefulness to NI within 10 to 20 minutes of lights out and follows through N2 to N3 before REM sleep. REM sleep occurs within
75-90 minutes of sleep onset and alternates with NREM sleep at 90 minutes intervals 2,6 In an overnight sleep there are usually 4-5 REM-NREM cycles.6 Disturbances in the pattern and periodicity of these phases are often found when people complained of
One of the earliest epidemiological surveys on sleep disorders conducted in Los Angeles in the 1970s revealed a prevalence of insomnia of 32.2%.7 In another study in Brazil the prevalence of poor sleep was 33.7%.5 Vozoris, reported 30% prevalence of insomnia among the United States of America adult population.8
In Nigeria, James et al,9 reported a prevalence of 32.5% for poor quality of sleep among medical students. In another study, among elderly patients with tinnitus in Ibadan, 51.9% had insomnia.10 Adewole et al11 in their study among hospital workers reported that 19% of the respondents met the criteria for high risk obstructive sleep apnea. These indicate that sleep problems are common in the Nigerian population. Sleep disorders place a significant burden on the health care system through increased utilization.12 They are associated with considerable morbidity, mortality and substantial economic costs.4 Sleep disordered breathing and chronic insomnia are independent risk factors for hypertension.13
Sleep disorders are classified by the American Association of Sleep Medicine into eight according to the International Classification of Sleep Disorders version two (ICSD 2). These are: the insomnias, sleep related breathing disorders, hypersomnia of central origin, circadian rhythm sleep disorder, parasomnias, sleep related movement disorders, isolated symptom apparently normal variant and other sleep disorders. 14.
Insomnias: are abnormalities that produce either difficulty initiating or maintaining sleep.14 Hypersomnia of central origin: are disorders in which the primary complaint is daytime sleepiness.14 Sleep related breathing disorders: These include central sleep apnoea, obstructed sleep apnoea.14
Circadian rhythm disorders: These are sleep disturbances that are out of rhythm with the twenty-four hour clock.14 Parasomnias: are disorders of arousal and sleep stage transition. They intrude into the sleep process and are manifestations of CNS
activation.13 Sleep related movement disorders: These are conditions in which body movements delay the unset of sleep. Examples are restless leg syndrome and periodic
leg movement sleep disorder.14
The management of sleep disorders remains a complex challenge involving inputs from different specialists including the Family Physician who is usually the first port of call. Diagnosis requires careful history taking, examinations and laboratory investigation. A detailed sleep history is required including a sleep diary or recording of day and night pattern of sleep.16 Since sleep disorders may be associated with other major medical and psychiatry conditions, the approach to a patient with a sleep complaint should take into consideration other major medical conditions such as chronic pain, cardiovascular disease, dementia, gastrointestinal disorders and mental illnesses as well as a detailed psychiatry history.17 In addition, sleep questionnaires such as the Pittsburgh sleep quality index and Epworth sleepiness scale are often used to diagnose sleep problems. Specialised investigations such as polysomnograph and multiple sleep latency tests can also be performed usually in a sleep laboratory.18
Treatment of sleep disorders can be categorised into non-pharmacological and pharmacological modalities. The non-pharmacological approaches to management aim to reset the physiologic sleep regulating system. These include proper sleep hygiene, behavioural modification and cognitive therapy.19 Pharmacological treatment involves the use of hypnotics such as benzodiazepines and non-benzodiazepines. Others are melatonin receptor agonists. Obstructive sleep apnoea is usually treated with continuous positive airway pressure (CPAP), while amphetamines are used to induce
alertness in patients that are somnolent.20
Sleep disorders are common in the population and are among the most common complaints seen by Family Physicians.15 They are either the main complaint or a complication of many conditions for which patients are seen in primary care or referred to the specialist clinic.15 In order to care for patients holistically, their sleep experience should be a routine part of the clinical interview in Family Medicine.
1.2 STATEMENT OF THE PROBLEM
Sleep problems continue to cause considerable burden across the globe.15, 21 They are associated with cardiovascular disease, mental health problems, motor vehicle accidents and overall poor quality of life.22 Sleep deprivation also increase mortality, errors and absenteeism in work place, decrease in production and deterioration of personal and professional relationships.23 Lack of sleep impairs a person’s ability to focus and learn efficiently.24 The direct and indirect costs of sleep problems are substantial.22 In Nigeria, several studies have shown that sleep problems constitute a
huge burden.25, 26, 27 Sleep walking was associated with violence and the experience was psychologically disturbing25 while snoring was associated with obstructive sleep apnoea.26 Sleep deficit was identified as a significant cause of road traffic accident.28 The overall rate of medical consultation was also higher in patients with sleep disorders than in those without.5 Sleep hygiene is poor in most developing countries with sleep problems under diagnosed and in most cases misdiagnosed.7,29,30 The fact that sleep disorders were associated with several morbidities, most strongly psychiatric disorders as well as increased mortality, underscores the importance of sleep problems as
indicators of health status.4
A study carried out in Canada showed that General Practitioners are the most frequently consulted for sleep problem.31 In Family Practice in Nigeria, information on sleep disorders is largely unavailable yet most patients with this problem present to the Family Physicians. Despite the individual and societal burden of sleep problems, most remain undiagnosed. In order to take care of patients holistically, sleep-related issues should be competently managed in Family Practice. Hence the need for this study to determine the prevalence and pattern of sleep disorders among patients attending the Family Medicine clinic in Obafemi Awolowo University Teaching Hospital Complex
1.3 AIM AND OBJECTIVES
To assess the burden of sleep disorders among patients presenting at the Family Medicine clinic in Obafemi Awolowo University Teaching Hospital complex Ile Ife, with a view to ensuring early detection and providing strategies to improve sleep quality.
- To determine the prevalence of sleep disorders among patients attending the
Family Medicine clinic in OAUTHC.
- To determine the pattern of sleep disorders among the subjects.
- To identify the factors associated with sleep disorders.
1.4 JUSTIFICATION FOR THE STUDY
Sleep disorders constitute common problem worldwide,15,20,21 and is often an unrecognised and seldom examined component of illness that impacts on the health status of individuals. 32 It has been found that 50% of all primary care patients report sleep problems.33 In an urban primary care setting, 71% had clinically significant sleep disturbances.32 Studies have also shown that both subjective and objective sleep disturbances are more pronounced among blacks compared to whites. 34,35 In a survey of Primary care physicians in USA, respondents were of the opinion that a patient’s sleep experience should be an essential part of routine consultation, however only about
52% of physicians surveyed conducted regular sleep assessments.35
Despite the high prevalence of sleep disorders and their consequences, sleep complaints usually go unnoticed by primary care physicians36,37 who provide most of the care to patients with the various conditions that precipitate sleep complaints like life stressors, concomitant illnesses, family and social dysfunctions.38
In Nigeria, there is paucity of data regarding the prevalence of sleep disorders generally. Various authors have looked into different aspects of sleep disorders in selected populations.8-10 In particular, there is scarcity of local data on the pattern and prevalence of sleep problems among patients in Family Medicine Clinic in Nigeria. Family Physicians are responsible for the care of the undifferentiated patient irrespective of the age, sex and diseased organ. They are also involved in health promotion, disease prevention and routine medical check up. It has been shown that Family Physicians are the most consulted for sleep problems. Therefore, patients with sleep disorders and those at risk such as the elderly and those with chronic medical conditions can easily be identified in a family practice clinic.
There is a need for accurate data on sleep disorders providing comprehensive overview of the burden of sleep disorders in Family Medicine. This will provide evidence for appropriate interventions such as sleep health education, which is not expensive and could be administered in a Family Practice set up. This study will therefore provide data on the burden of sleep problems among patients seen at the Family Medicine clinic in OAUTHC. This study will contribute to the knowledge of assisting and formulating interventions for patients with sleep related disorders.
PATTERN OF SLEEP DISORDERS AMONG ADULT PATIENTS PRESENTING AT THE FAMILY MEDICINE CLINIC OF OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITAL COMPLEX ILE IFE