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of Sleep Apnea Syndrome
in Middle-aged Men and Women
Because of current concern that a large proportion of people with sleep apnea in the community are going undiagnosed and untreated, the authors compared the frequencies of clinically diagnosed sleep apnea and sleep apnea detected by a screening of the population in an ongoing project, the Wisconsin Sleep Cohort Study.
The subjects were drawn from a group of five thousand state employees, aged 30-60 who were mailed a questionnaire. This population had ready access to a sleep disorders clinic and adequate, identical insurance coverage for sleep evaluation. A subset of 22% of this group had laboratory sleep studies. These two measures—the questionnaire and the sleep study—represented the screening of the population for sleep apnea syndrome (SAS).
Subjects were considered detected by the screening for SAS if they reported excessive sleepiness “often” or “almost always,” or if they reported feeling unrested no matter how much they slept. Also they were required to show five or more apneas or hypopneas per hour of sleep. Fifteen or more were considered to define moderate to severe SAS on the screening.
From the results of this screening, it was estimated that 2.1% of the population—1.0% of women and 3.4% of men—had moderate to severe SAS. Inclusion of mild SAS would raise these numbers to 5.0% of the population, 3.5% of women and 6.8% of men. In terms of actual numbers, 104 patients in the overall group of five thousand were estimated to have moderate to severe SAS.
Clinically diagnosed patients with SAS were determined by mail and telephone follow-up, which indicated only 0.32% of the population (16 people in all, including 14 men and 2 women) had been examined or tested and told they had SAS. Of these 16, all but three had received treatment. An additional 30 subjects admitted they suspected they had sleep apnea but had not been examined or diagnosed.
Based on these figures, the authors estimated that mild to moderate SAS in this population went undiagnosed in 82% of affected men and 93% of women, while mild SAS went undiagnosed in 90% of men and 98% of women.
Characteristics of subjects that were associated with a better chance of being diagnosed with SAS were: male sex, a history of cardiovascular disease, older age, Caucasian race, higher income, and higher education. Some of these predictive factors suggested inequitable care. It was also suggested that the prevalence of SAS might be still higher if the population had included people older than 60.
The results of this study confirm growing conviction that the vast majority of sleep apneics in the general population go undiagnosed. That this is true even with a working population of middle-aged men and women who have adequate insurance and access to a sleep center suggests that the picture for the country as a whole would be even worse.
The total U.S. population, compared to that under study here, would certainly include many people without jobs or health insurance or easy access to sleep centers, unlike the population studied here. It would also include many older people, though the higher frequency of SAS expected in that group might be to an uncertain extent offset by the inclusion of younger people as well. The general U.S. population would include a higher proportion of non-Caucasians than the 7.3% in the population studied here. It also seems likely that the general population would have a lower average income and education level.
These findings support a greater societal investment in educating both doctors and public to greater awareness of the signs and symptoms of SAS, its many disabling or even fatal complications, and especially its responsiveness to treatment. These facts combined incidate that, from a purely economic perspective, the results of such an investment would prove profitable to all concerned.
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