Sleep apnea in women veterans: results of a national survey of VA health care users

Prevalence of Obstructive Sleep Apnea Among Veterans and Nonveterans

PURPOSE

Understanding disease prevalence can inform treatment and resource needs across populations. This study aimed to identify the prevalence of sleep apnea (OSA) among veterans and nonveterans.

DESIGN

The national Comparative Health Assessment Interview Study, cross-sectional survey using probability-based sampling frames.

SETTING

Surveys completed by Internet or phone.

SUBJECTS

15,166 veterans (40% response rate) and 4,654 nonveterans (57% response rate).

MEASURES

Self-report of healthcare provider-based diagnosis of OSA.

ANALYSIS

Calculation of prevalence of OSA using statistical weighting to allow for direct comparison between veterans and nonveterans. Secondary analyses evaluated OSA by deployment status among veterans and compared average age of OSA diagnosis and differences in OSA prevalence among veterans and nonveterans stratified by gender, marital status, race/ethnicity, and posttraumatic stress disorder diagnosis.

RESULTS

OSA diagnosis was more than twice as prevalent among veterans (21%, 95% CI 20%-22%) than nonveterans (9%, 95% CI 8%-10%; aOR: 2.56, 95% CI 2.22-2.95, P < .001). Deployment was associated with higher odds of OSA among veterans (aOR: 1.64, 95% CI 1.43-18.7, P < 001.) Veterans were diagnosed with OSA on average 5 years earlier than nonveterans.

CONCLUSION

Veterans have a high prevalence rate of OSA, highlighting the importance of veterans' access to treatment. OSA is likely underdiagnosed in nonveterans, particularly among racial/ethnic minoritized groups. Future research should investigate disparities in access to diagnostic testing for racial/ethnic minority nonveterans and/or risk factors for OSA among racial/ethnic minority veterans. The increased odds of OSA among those with PTSD highlights in the importance of early referral for OSA testing by providers as well as development of trauma-informed strategies to promote OSA treatment adherence. Limitations include a bias toward underestimation of true disease prevalence due to self-report of diagnosis.

Sleep Apnea Among Gulf War Veterans: An Examination of VA Utilization Rates, Treatment Initiation, and Health Outcomes

OBJECTIVES

Obstructive sleep apnea (OSA) among veterans is frequently underdiagnosed and undertreated. The present study sought to: 1) characterize the prevalence and rate of treatment of OSA among VA users and non-users and 2) examine the associations between diagnosed or probable OSA and key physical and mental health outcomes.

METHODS

Gulf-War I-era Veterans were recruited as part of a national survey assessing mental and physical health concerns, healthcare needs, and healthcare utilization. OSA diagnoses were self-reported while sleep apnea risk was assessed via the STOP-Bang. Veterans also completed questionnaires assessing overall health, pain, depression, PTSD, and psychosocial functioning.

RESULTS

1,153 veterans were included in the present analyses (Mean age = 58.81; 21.84% female). Compared to non-VA healthcare users, veterans receiving care at the VA were more likely to have been diagnosed with OSA (p < .001) and report receiving treatment for OSA (p = .005). Compared to veterans at low risk for OSA, veterans at elevated risk reported higher levels of pain (p = .001), depression (p = .02), and poorer psychosocial functioning (p < .001).

CONCLUSIONS

OSA diagnoses appear to be more common among VA healthcare users. Findings suggest that OSA remains underdiagnosed and associated with important physical and mental health consequences. Additional screening for OSA, especially among non-VA clinics, is warranted.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist.

OBJECTIVES

This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes.

METHODS

We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed.

RESULTS

Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers.

DISCUSSION

Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans

PURPOSE

Sleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk.

METHODS

Within one VA healthcare system, women identified through electronic health record data as having one or more factors (e.g., age >50 years, hypertension) associated with SDB, completed telephone screening in preparation for an SDB treatment study and answered questions about prior care related to SDB diagnosis and treatment.

RESULTS

Of 319 women, 111 (35%) reported having completed a diagnostic sleep study in the past, of whom 48 (43%) were diagnosed with SDB. Women who completed a diagnostic study were more likely to have hypertension or obesity. Those who were diagnosed with SDB based on the sleep study were more likely to have hypertension, diabetes, or be ≥50 years old. Of the 40 women who received treatment, 37 (93%) received positive airway pressure therapy. Only 9 (24%) had used positive airway pressure therapy in the prior week. Few women received other treatments such as oral appliances or surgery.

CONCLUSIONS

Findings support the need for increased attention to identification and management of SDB in women veterans, especially those with conditions associated with elevated SDB risk.

Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.

Comorbidities and quality of life in Australian men and women with diagnosed and undiagnosed high risk obstructive sleep apnea

STUDY OBJECTIVES

In a population-based survey, we determined sex-differences in health profiles and quality of life between individuals who have a confirmed diagnosis of obstructive sleep apnea (OSA) and those who are at high risk of OSA yet remain undiagnosed.

METHODS

An online survey of Australian adults ≥18 years (n= 3818) identified participants with self-reported diagnosed OSA (n=460) or high risk, undiagnosed OSA (OSA50 score ≥5, n=1015). Ever-diagnosed comorbidities, sociodemographic and quality of life (EQ-5D-5L, Functional Outcomes of Sleep Questionnaire-10) were assessed.

RESULTS

Females were more frequently represented in the high OSA risk group compared to diagnosed OSA (55.5%, n=563 cf 43%, n=198) p<0.001. In sex-specific logistic regression analyses, diagnosed OSA was associated with increased likelihoods of ≥1 cardiovascular condition (odds ratio:3.0, 95% CI:2.0-4.5), hypertension (1.9, 1.3-2.8), gout (1.8, 1.1-2.9) and COPD (3.8, 2.1-6.9) in males. In females an association with asthma (2.0, 1.3-3.0) was seen. Diabetes, arthritis, mental health conditions (ever-diagnosed) and all EQ-5D-5L dimensions were associated with an OSA diagnosis regardless of sex with the exception of EQ-5D-5L anxiety/depression which was only associated with an OSA diagnosis in females. A diagnosis of OSA was associated with sleepiness related impairment (lowest quartile of FOSQ-10) in males (1.6, 1.01-2.5) and females (2.2, 1.4-3.6).

CONCLUSIONS

Sex-specific health conditions may drive diagnosis of OSA however a clinical suspicion of OSA needs to be increased in men and women. The impaired quality of life and persistent sleepiness in participants with diagnosed OSA observed at a population level requires greater clinical attention.