Physicians tell Congress Americans need sleep
Physicians tell Congress Americans need sleep
Sleep disorders cost roughly $100 billion annually
Americans can't sleep, and it's costing us billions in lost productivity, automobile and work-related accidents, and for health care. A 1996 report by the National Highway Traffic Safety Administration in Washington, DC, estimated that 1,500 deaths and 76,000 injuries occur annually because drivers fall asleep at the wheel. The total cost is $12.4 billion.
Sleep experts recently took the message that sleep disorders represent one of the nation's most serious and underrecognized health problems before the House Subcommittee on Health and Environment, chaired by Rep. Michael Bilirakis (R-FL). Many physicians fail to take the time to recognize signs of sleep disorders, including serious health concerns such as obstructive sleep apnea, narcolepsy, and insomnia, says Clete A. Kushida, MD, PhD, staff physician and clinical instructor at the Stanford Sleep Disorders Clinic and director of the Stanford Center for Human Sleep Research at Stanford University in Stanford, CA.
Left untreated, obstructive sleep apnea increases the risk of hypertension, heart disease and heart attack, stroke, automobile and work-related accidents, and sudden death due to cardiac arrhythmia, Kushida notes. Yet, the problem is easily diagnosed and treated, he says. The most common treatment for obstructive sleep apnea is continuous positive airway pressure (CPAP), he says, adding that the CPAP machine provides a gentle flow of air through a mask to keep the airway open during sleep.
Kushida is part of a group of Stanford researchers involved in the Stanford Primary Care Sleep Education Project that provides education and consultation on the diagnosis and treatment of sleep disorders to primary care physicians. To date, the project has been implemented in Walla Walla, WA, and Moscow, ID. The project recently expanded to a third site in Alamo, CA.
Sweet dreams
Researchers conducted chart reviews, administered patient questionnaires, and tabulated polysomnographic data from the Walla Walla project and compared it with published reports from specialized sleep centers. Results of the project include the following:
· For a two-year period from 1992 to 1994, 360 new patients underwent polysomnogram testing.
· Of those patients, 81% had sleeping-related breathing disorders, and 18% experienced periodic leg movements in their sleep.
· More than 225 patients received CPAP.
· Chart reviews of 752 patients found that before the project, physicians only suspected a specific sleep-related disorder in six cases, and only two patients were referred for polysomnography.
Preliminary data from the Moscow project indicates that sleep disorders are as common in Idaho as they are in Washington. In a study of 975 patients, researchers found that 32% suffered from insomnia, 19% from sleep apnea, and 25% from restless-leg syndrome. The detailed patient surveys were completed in March and currently are being compiled by Stanford researchers.
"Treating most sleep-related disorders is not difficult as long as physicians recognize the symptoms," says Kushida. "The Walla Walla and Moscow projects included typical groups of patients in rather typical American communities. Relatively few of these patients probably need a referral to a specialty clinic. Many are being helped or cured with simple measures such as short-term sleep medication or even educational counseling." (For suggestions on how to get a good night's sleep, see p. 112. For more helpful suggestions on improving sleep, see list of sleep-related Web sites, p. 111.)
In addition to creating serious health problems, sleep disorders can slow recovery or delay return-to-work, notes Deborah A. Nichols, MS, Northwest regional director of the Stanford primary Care Sleep Education Project at Stanford University. "I had a patient walk into my office who had just had a plantar wart removed," says Nichols, who is the study's project director in Moscow, ID. told me he was starting a construction business but was afraid to work because he couldn't sleep. He hadn't mentioned it to his doctor because he hadn't even thought of sleep as a relevant topic to bring up."
Do you wake refreshed?
Patients with chronic fatigue, carpal tunnel syndrome, and low back pain are among the populations that routinely experience fragmented sleep, leaving them fatigued and slowing their recovery, Kushida says. "If you have elderly patients with a chronic disease syndrome, their chances of getting decent sleep are even more limited."
Uncovering a sleep disorder may prevent serious health consequences and reduce medical costs, Nichols says. Symptoms include:
·snoring, interrupted by periods of silence or pauses in breathing;
· gasping or choking during sleep;
· restless sleep;
· excessive sleepiness or fatigue during the day;
· poor judgement;
· irritability;
· memory loss;
· depression;
· morning headache;
· sexual dysfunction;
· frequent urination in the night.
Questions Kushida and Nichols suggest case managers ask patients to assess the possibility of a sleeping disorder include:
· Do you snore?
· Do you experience daytime sleepiness throughout the day?
· Has your bed partner mentioned that you have breathing pauses in your sleep?
· Do you have enough sleep at night?
· Do you wake repeatedly at night and find it difficult to go back to sleep?
· Do you take longer than 30 minutes to fall asleep?
· Do your legs twitch during the night, or do you have disagreeable sensations in your legs that cause you to move them?
· Do you walk or have other unusual movements in your sleep?
· Do you fall asleep in front of the television?
· Do you fall asleep while driving?
If you suspect a patient has sleep apnea, you must have them checked by a sleep specialist, Kushida and Nichols say. "Sleep disorders are extremely common in primary practice. Case managers should ask questions about sleep issues and encourage physicians to ask them, too," says Nichols.
Suggested reading
1. Ball EM, Simon RD, Tall AA, et al. Diagnosis and treatment of sleep apnea within the community: The Walla Walla project. Arch Intern Med 1997;157: 419-424.
2. Johns M. A new method of measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991; 14,540-14,545.
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