SUMMARY

During a baseline evaluation of 4578 elderly participants in the Cardiovascular Health Study, 16% reported being “usually sleepy in the daytime.” This symptom correlated with several measures of ill health. In a follow-up examination four years later, the same patients were given the Epworth Sleepiness Scale or ESS (see Glossary) for a more detailed and standardized description of this symptom. The overall group of participants were randomly selected from Medicare eligibility lists in four counties around the US. Study criteria excluded from participation those who were institutionalized, wheelchair-bound in the home, or being treated for cancer. In addition to multiple questionnaires and the ESS, participants were questioned about sleep habits such as waking frequently during the night, waking up groggy in the morning, snoring, gasping, and stopping breathing during sleep. Scales to measure depression, cognitive function, physical activity, social supports, angina, and medication use were also included. Lab tests available included spirometry (see Glossary)and Magnetic Resonance Imaging of brain structure. In their analyses, the authors used the ESS as the main dependent variable of interest, meaning that they looked at how well it was predicted by scores on measures which others had found associated with daytime sleepiness, such as age, race, Body Mass Index, waist circumference, education, use of sleeping pills, use of antianxiety pills, use of antidepressants, use of alcohol, snoring, snoring or gasping at night; frequent awakenings at night; asthma; hay fever; angina; depression; stroke; impaired lung function; physical activity; arthritis; high blood pressure; diabetes; smoking; social supports; and cognitive function. They also looked at the relationship of the ESS to the original question asked about daytime sleepiness. Participants averaged 76 years of age; there was a slight predominance of women (59%). On the ESS, the average score was 5.85 (SD=+/- 4, ranging from 0 to 24, the maximum possible score. The women reporting poor health had ESS scores almost twice as high as those reporting excellent health (7.5 vs. 4.1). Those participants who had originally reported being usually sleepy in the daytime four years prior had higher ESS scores now than those who hadn’t (8.2 vs. 5.2). Men had generally higher ESS scores than women; the authors considered a “high” ESS score to be over 11 for men and over 9 for women. This distinction differentiated even more markedly those who had and hadn’t previous complained of daytime sleepiness. Other factors predictive of higher ESS scores included frequent awakening (usually attributed to need to urinate), coughing, snoring, and leg cramps. Two-thirds of participants reported others telling them that they snored lously. Higher ESS was also associated with non-white race, weight, BMI, waist and hip circumference; hayfever; arthritis; diabetes; depression; limitations of daily activities; and less exercise. Only in women, ESS was associated with high blood pressure, congestive heart failure, stroke, impaired cognitive function, and less than daily coffee drinking. In men, it was associated with nonsmoking; asthma; angina, congestive heart failure, greater support, more sedentary lifestyle. There was no association with age, education, or brain MRI variables. Sleeping pill use during the past year was reported by 12% of women and 9? Of men. Interestingly, use of these drugs was associated with slightly less drowsiness, at least in women. Antianxiety medications, taken by 9.1% of women and 5.2% of men, showed no relationship to daytime sleepiness. Although electroacardiographic measure of congestive heart failure did not predict daytime sleepines, the use of medications for heart disease and hypertension did. Both men and women with higher depression scores had higher ESS scores. So did participants who reported sleep disturbances. The authors mentioned that the average ESS scores were similar in these elderly participants to those in a younger healthy group, but in the elderly there was a large group (13%) with scores in the upper range considered pathological. This occurred more frequently in men and non-whites. Various markers associated with Obstructive Sleep Apnea—among which the authors included sleep disruption, depression, diminished physical activity, heart disease, and age—were also related to high ESS. There is data to suggest the prevalence of OSA may be increased in blacks, possibly related to differences in craniofacial anatomy. Several measures of obesity were associated with high ESS, but only one—hip circumference—was an independent predictor. Nocturia (having the urinate frequently at night) and nighttime leg cramps (possibly related to periodic leg movements of sleep) were also predictors of ESS. Exercisem, which is thought to benefit sleep, was negativel associated with ESS. Chronic illness, which may disrupt sleep with pain, shortness of breath, or frequent urination, was association with excessive dayhtime sleepiness even though specific laboratory measures of pulmonary, cardiac, and brain did not show such a relationship. Although it is commonly considered that sleeping medications and antianxiety medications contribute to excessive daytime sleepiness in the elderly, this relationship was not observed in the data from this study. Here the relationship seemed to be primarily with indications of an underlying sleep disorder such as OSA or PLMD, or some other chronic illness.

COMMENTS

The large number of subjects in this study and their widely separated geographical distribution in four different areas of the country should increase our confidence that they are representative of the population of noninstitutionalized elderly as a whole. Althought the data from this study, without a control group of younger participants, cannot be taken to demonstrate more frequent daytime sleepiness among the elderly, it does show a substantial minority (13%) of these elderly people to have a significant degree of subjective daytime sleepiness, which is further supported by the correlation of this self-report with multiple other measures consistent with the problem. Furthermore, the simple complaint made four years previously of daytime sleepiness was strongly associated with elevated scores of the Epstein Sleepiness Scale on reevaluation. In other words, the study seems to have identified a subgroup of elderly people with real, significant, and persistent excessive daytime sleepiness. Those afflicted seem to be more often men and non-white, more often obese, with other signs and symptoms of sleep disorders, especially Obstructive Sleep Apnea, though other factors such as Periodic Leg Movements of Sleep and the adverse effects on sleep of various chronic illnesses were also evident. This is, one might say, a picture we might expect to find, though with a few expected features missing, such as no greater cognitive impairment, and no greater use of sedative medications such as sleeping medications and antianxiety medications, than elderly people who were not excessively sleepy. On the other hand, some cardiac and antihypertensive medications did appear to contribute to the symptom.





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