Doctors, Patients and Sleep
A survey of family practitioners in the United States has shown that doctors in general do not ask their patients about sleep. In fact, 96% of doctors wait for the patient to initiate any discussion about their sleep. Some of the reasons they gave were that it takes time away from dealing with their patients’ other medical problems (70%), that they feel inadequately trained in this area (80%), that they have too few diagnostic tools (80%), and that there are too few effective treatments (54%). Considering that obstructive sleep apnea has been shown to be unequivocally related to hypertension *, and there is a good deal of evidence it is also related to coronary artery disease, CVA, diabetes, road traffic accidents, and mood related disorders such as anxiety and depression, the first explanation above is clearly inappropriate. Considering that it is often easily diagnosed with home oximetry, and that polysomnography even in B.C. is now available within a matter of a few weeks if not days, and that extremely effective treatment is available in the form of Continuous Positive Airway Pressure (CPAP), the third and fourth explanations above are inaccurate. The only possible excuse that doctors have for their failure to take a sleep history is inadequate training. This needs to be addressed by the medical community.
The above survey led Richard Galula, the executive director of the National Sleep Foundation in the US, to comment, “While our survey shows primary health care physicians believe sleep is important and it should be part of a regular check up, they do not feel they can take the time to discuss it … the paradox happening in doctors’ offices can be dangerous to your health”.
If we look at the problem of hypertension alone, it is of note that the US Joint National Committee on Prevention of Hypertension merely mentioned obstructive sleep apnea in 1997, but now puts it at the top of the list of identifiable causes. Doctors treating hypertension should be particularly suspicious of underlying obstructive sleep apnea if hypertension is resistant to treatment. Severe snoring, a family history of OSA, obesity (both a cause and effect of OSA), dysrythmias (particularly bradycardias and atrial fibrillation), and congestive cardiac failure, are also red lights for obstructive sleep apnea.
It is incumbent upon the medical profession to become familiar with this important underlying cause of highly prevalent and serious disease. And in the meantime it seems to be important for patients concerned about their sleep, or concerned about their partner’s sleep, to broach the issue directly and emphatically with their doctor.
* Review article: OSA: Implications for Cardiac and Vascular Disease. Shanasuzzaman et al., JAMA, Oct. 03; 290:14.
Richard R.J. Smyth, M.B.B.S., F.R.C.S.
Director, Sleep Surgery Centre