Expanding Awareness About the Serious Health Consequences of Undiagnosed Obstructive Sleep Apnea: Thinking Outside of the Box to Identify Patients at Risk

^{By: Yvette C. Terrie, RPh, Consultant Pharmacist}

In the United States, sleep disorders are very common and represent a major public health issue. Obstructive sleep apnea (OSA) is one of the most frequently occurring sleep disorders and is often known as the sleep condition in which individuals snore. It is important to note that not everyone who snores has OSA. OSA is so much more than snoring and is associated with unusual daytime drowsiness and fatigue. It is also linked with a plethora of serious health consequences if it remains undiagnosed or untreated. The American Sleep Apnea Association states that an estimated 25 to 30 million Americans suffer from OSA, with 75-80% of the cases of moderate and severe obstructive OSA remaining undiagnosed.¹

Why is More Screening Warranted and the Dangers Associated With Undiagnosed OSA?

Unfortunately, even though the statistics for those at risk for OSA are alarming, many cases remain undetected for several reasons. Moreover, population studies have revealed that OSA has steadily been undiagnosed, yet extensively prevalent, among many at-risk patients in the US.²  With the majority of OSA cases still undiagnosed, it is imperative that health care providers increase awareness about this serious sleep related breathing disorder that is linked with or exacerbates a plethora of medical conditions.  For example, many health care providers are still under the impression that OSA is associated with the overweight middle-aged male with the thick neck. It is important to note that OSA affects a varied assortment of patients including pediatric patients. Moreover, health care providers should dispel the myths and misconceptions about the “stereotype” of what an OSA patient looks like. For example, according to the Cleveland Clinic, many are not aware that women face an increased risk of OSA as they age due to post-menopausal  hormonal changes, but could also be the result of functional changes in the upper airway.³ Recently published research indicates that with regard to OSA, women often experience symptoms in a different way than men do.⁴ That distinct symptomatology, in conjunction with the persistent, misguided OSA stereotypes, results in the great majority of women with OSA going undiagnosed—or misdiagnosed with another condition.⁴ Research indicates that approximately 1 in 4 women in the United States is at high risk for OSA and an estimated 90% of women with OSA remain undiagnosed.⁴ Additionally, while more women have been diagnosed with OSA in recent years, the numbers remain disproportionate, with 3-to-5 times more men than women receiving an OSA diagnosis.⁵ Moreover, results released from a study in April 2020 stated that African Americans with severe OSA and other adverse sleep patterns are much more likely to have elevated blood glucose levels than those without these patterns.⁶

Many patients are unaware that undiagnosed and untreated OSA increases the risk for or worsens a host of health problems, including cardiovascular disease such as hypertension, myocardial infarction, ventricular hypertrophy, chronic heart failure, atrial fibrillation, stroke, coronary artery disease as well as non-alcoholic fatty liver disease (NAFLD), obesity and type 2 diabetes.^1,7  There is also mounting evidence linking the sleep disorder to major depression and other issues such as anxiety.^1,7 Some affected patients complain of morning headaches and neurocognitive difficulties such as problems concentrating and memory issues. Some studies have linked sleep apnea with an increased risk of dementia, ADHD and development of cancer. Researchers in a recently published study in JAMA Neurology disclosed that they found a correlation between sleep apnea and the presence of amyloid plaques and other biological changes associated with inflammation and Alzheimer’s disease.⁸ It is quite clear that undiagnosed and untreated OSA is associated with serious health consequences and increased morbidities and premature mortality rates.

 To increase the diagnosis of OSA, it is imperative that health care providers ask their patients about sleep patterns and sleep habits to assess if they may be exhibiting signs and/or risk factors for OSA. For example, women with polycystic ovarian syndrome (PCOS) should be screened for OSA since there is a correlation between the two conditions and many are not. Studies indicate that more than 50% of women with PCOS also have OSA. A 2019 study revealed that women with PCOS are more than twice as likely to develop sleep apnea.⁴ Health care providers should also be aware of other OSA risk factors for example, patients who have a smaller lower jaw or other facial configurations, large tonsils, large tongue, smaller airway behind the tongue, longer and thicker soft palate, post-menopausal women, those with hypothyroidism or acromegaly.⁹

In addition to the health burden of OSA, it also presents with a significant economic burden on the health system. A 2016 report commissioned by the American Academy of Sleep Medicine estimated that undiagnosed OSA among US adults costs $149.6 billion annually.¹⁰ While the report projected it would cost the health care system nearly $50 billion to diagnose and treat every American adult with OSA, treatment would produce savings of $100 billion.¹⁰ Another recent study stated that patients hospitalized for exacerbations due to COPD face a twice greater risk of readmission within a month when they also suffer from untreated, mild OSA. These results demonstrate more evidence of the health and economic burdens associated with undiagnosed OSA and care in the United States and the impact more severe cases may have on hospital resources and personnel. ¹¹

Recognizing and treating OSA is critical, because when it is left undiagnosed and untreated, it can be detrimental for many patients, increases the risk for serious medical consequences and augments premature mortality and health care utilization costs. As one of the most accessible health care professionals, pharmacists can have a major role in screening patients for OSA. One study revealed that pharmacists were able to identify between 21.4 and 67 % of patients that were at risk for developing OSA or required a referral to a general practitioner or sleep disorder specialist for further diagnostic testing.¹²  By engaging patients in conversation and asking certain questions about sleep habits and quality of sleep, we can ascertain whether a patient is at risk for or is exhibiting signs of OSA and make clinical referrals as warranted especially in those patients that do not fit the “stereotypical” OSA patient profile. With proper diagnosis and adherence to therapy, patients’ sleep patterns, health and overall quality of life can be significantly improved.

As health care professionals, we can increase knowledge about the dangers of undiagnosed and untreated OSA and empower our patients with knowledge about OSA and in turn enable them to make informed decisions about their health in conjunction with their primary health care provider. Since the majority of cases of OSA go undiagnosed, it is imperative that health care providers screen patients using known risk factors, symptoms and assessment tools.  The alarming percentage of patients that remain undiagnosed and the serious health complications associated with undiagnosed and untreated OSA should be a WAKE-UP call for all of us.

Yvette C. Terrie, is a consultant pharmacist, medical writer and creator of A Pharmacist’s Perspective (https://apharmacistsperspective.blogspot.com/ ).

References

1. OSA Information for Clinicians. OSA. https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/.  Accessed April 29, 2020.
2. Kunzmann K. Reena Mehra, MD, MS: The Struggle to Diagnose OSA. MD Mag website. https://www.mdmag.com/medical-news/reena-mehra-diagnose-osa . Published September 12, 2019. Accessed April 29, 2020.
3. OSA especially dangerous for women’s hearts. Cleveland Clinical website. https://health.clevelandclinic.org/sleep-apnea-especially-dangerous-for-womens-hearts/  Published February 2019 .
4. Psychology Today. 2020. New Findings On OSA In Women. Psychology Today website. https://www.psychologytoday.com/us/blog/sleep-newzzz/201906/new-findings-sleep-apnea-in-women .  Published June 26, 2019. Accessed 29 April 2020.
5. Brigham Women’s. Study suggests women may be undertreated for obstructive OSA. EurekAlert! https://www.eurekalert.org/pub_releases/2019-11/bawh-ssw112519.php . Accessed April 29, 2020.
6. New study links severe OSA to higher blood glucose levels in African Americans. National Institutes of Health. https://www.nih.gov/news-events/news-releases/new-study-links-severe-sleep-apnea-higher-blood-glucose-levels-african-americans . Published April 28, 2020. Accessed April 29, 2020.
7. Boyles S. Clinical Challenges: OSA, Depression, and Anxiety. Medical News and Free CME Online. https://www.medpagetoday.com/clinical-challenges/chest-sleep/82976 . Published April 29, 2020. Accessed April 29, 2020.
8. André C, Rehel S, Kuhn E, et al. Association of Sleep-Disordered Breathing With Alzheimer Disease Biomarkers in Community-Dwelling Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol. Published online March 23, 2020. doi:10.1001/jamaneurol.2020.0311
9. Risk Factors for OSA. Harvard Medical website. https://healthysleep.med.harvard.edu/sleep-apnea/what-is-osa/risk-factors . Accessed April 29, 2020.
10. Older undiagnosed OSA patients need more medical care. American Academy of Sleep Medicine EurekAlert! https://www.eurekalert.org/pub_releases/2020-01/aaos-ous011620.php . Published January 16, 2020. Accessed April 29, 2020.
11. Naranjo M et al. Undiagnosed obstructive sleep apnea may significantly impact outcomes in adults admitted for COPD in an inner-city hospital. CHEST. April 2020. https://doi.org/10.1016/j.chest.2020.03.036.
12. Cawley MJ, Warning WJ 2nd. A systematic review of pharmacists performing obstructive sleep apnea screening services. Int J Clin Pharm. 2016;38(4):752‐760. doi:10.1007/s11096-016-0319-0