Primary Care: Is It the Setting to Address Sleep Disorders?

 

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Although largely ignored in the early evolution of sleep medicine, interest in the need to improve recognition of sleep disorders in primary care patient populations is beginning to increase. The study by Kushida et al. in this issue of Sleep and Breathing presents data strongly supporting a very high prevalence of sleep disorders in the primary care setting. These authors report that 60.1% of patients interviewed consecutively for one year presented unambiguous symptomatology at levels of severity deemed highly likely to be confirmed by polysomnographic testing. On the other hand, nearly all the symptomatic patients in the study of Kushida et al. had not been previously recognized. Moreover, in the entire scientific/clinical literature there is no evidence whatsoever that more than a tiny fraction of patients afflicted with sleep disorders receive specific diagnoses and the appropriate, beneficial treatment from primary physicians. This deplorable state of affairs co-exists with an enormous scientific literature documenting the morbidity and mortality consequences of these disorders. Even as we embark upon the third millennium, the continuing failure to recognize sleep disorders in primary care medical practice constitutes a major personal and public health crisis that absolutely must be addressed. We will herein review some of the problems, issues, and possibilities involved in meeting this challenge.

Issue #1-Can We Consider the Very High Prevalence of Sleep Disorders in Primary Care Populations an Established Fact?

All types of sleep disorders probably exist in a higher prevalence among the primary care patient population than in the general population, and very likely at higher levels of severity. Why might this be true? One reason is the nature of medical practice, where most encounters (> 85%) are for chronic and acute disease.[1] This results in an enriched profile for risk factors. For example, in the Cleveland cohort studied with the Berlin Questionnaire (see Appendix), 50% of a consecutively studied primary care patient population was obese and/or hypertensive.[2] Moreover, such patients were more likely to visit their family doctor than healthy adults.

Prior studies in primary care have emphasized a single sleep disorder. Several reports have emphasized insomnia in younger[3] [4] [5] and geriatric populations.[6] [7] Sochat and Ancoli-Israel[8] found 69% prevalence for insomnia in older patients. They suggest that the primary care population has a higher prevalence of insomnia than the general population because of concomitant psychiatric and medical illness.

Stoohs et al.[9] showed a high prevalence of sleep disordered breathing in a sample of primary care patients. The high prevalence of sleep disordered breathing was confirmed in a larger sample by Netzer et al.[2] using the Berlin Questionnaire. Pediatricians first acknowledged the need for the family practitioner to recognize sleep disorders in the infants and children they cared for because parents often sought advice from their family doctor first before they went to a pediatrician or to one of the (rare) pediatric sleep specialists.[10] [11] [12] In 1993, the Wisconsin cohort study reported an obstructive sleep apnea population prevalence of 24% in adult men and 9% in adult women[13], with 2 to 4% showing clear symptoms. Already identified as a public health problem, the Wisconsin cohort results removed all doubt of the high prevalence of a major sleep disorder.

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