Identifying Risk of Sleep Apnea and Major Hospital Events in an Older Inpatient Population

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Obstructive sleep apnea (OSA) is characterized by periodic collapse of the upper airway, leading to reduced oxygenation and sleep disturbances1. Although common, affecting 2% to 26% of adults, up to 93% of women and 82% of men with OSA are undiagnosed1, 2. Older adults are at risk of OSA, but physicians infrequently report sleep apnea.3, 4 Data assessing OSA prevalence in hospitalized elderly adults are also limited. One recent study using the Berlin questionnaire reported a 40% risk of OSA in older inpatients5. The objective of this study was to determine the prevalence of risk of OSA and the association with major hospital events in hospitalized adults and older adults using questionnaires. This prospective cohort study spanned a 30-day period in January and February 2015 at Wake Forest Baptist Medical Center in Winston Salem, North Carolina. The Wake Forest Institutional Review Board study approved the study, and all enrolled subjects gave informed consent. All individuals aged 18 and older admitted to a general medicine or geriatric (aged ≥65) ward were identified. Individuals were excluded if they declined participation, were unable to complete questionnaires, were felt to be inappropriate based on medical severity, or were unable to consent (based on a subjective capacity evaluation). This study used two questionnaires designed to screen for risk of OSA. The STOP-BANG questionnaire evaluates risk based on questions about snoring, daytime tiredness, apnea, hypertension, body mass index (BMI) of 35.0 kg/m2 and greater, age of 50 and older, neck circumference of 40 cm and grater, and male sex. A score of 3 or greater has previously been defined as being at risk of OSAand scores of 5 or greater as being at high risk. Sensitivity is 84% to 100%, and specificity is 37% to 56%, depending on severity of OSA6, 7. The ISNORED questionnaire also screens patients at risk of OSA and asks about insomnia, snoring, not breathing, obesity (BMI ≥30.0 kg/m2), refreshed sleep, excessive daytime sleepiness, and diseases (cerebrovascular accident, hypertension, congestive heart failure, chronic pain, drugs)8. Risk of OSA based on ISNORED was defined as 3 or more positive answers. Self-reported BMI and neck circumference were also used9. An independently performed electronic chart review was performed to obtain information on demographic characteristics and comorbidities. Questionnaire statistics were analyzed using SAS version 9.3 (SAS Institute, Inc., Cary, NC). Of 177 individuals were admitted to a geriatric or general medicine ward, 102 (58%) completed the questionnaires. Individuals were excluded for declined participation (n=35), unavailability (n=25), severity of illness or cognitive impairment (n=11), incorrect protocol (n=2), no interpreter present (n=1), and end-of-life care (n=1). The mean age of individuals admitted to the geriatric ward (n=36) was 82 and to the general medicine ward (n=66) was 53. Those admitted to the geriatric ward had more documented comorbidities (2.5 vs 2.1). Rates of preexisting OSA were much lower in the older adults (5.7%) than the younger adults (24%) (p=.03). The prevalence of being at risk of OSA, defined as a STOP-BANG score of 3 and higher, was 80.6% on the geriatric ward and 78.8% on the general medicine ward. The prevalence of being at high risk of OSA, defined as a STOP-BANG score of 5 and higher, was 11.1% on the geriatric ward and 27.3% on the general medicine ward. For the ISNORED, 58.3% of those on the geriatric ward and 90.9% on the general medicine ward had a score of 3 and higher (Figure 1). A major hospital event occurred in 8.8% of all individuals (4 rapid responses, 3 respiratory distresses, 1 code stroke, 1 code blue followed by death). All individuals with a major hospital event were at risk of OSA according to a questionnaire, but there was no association between OSA risk and event rate. Prevalence of risk of obstructive sleep apnea on geriatrics and general medicine inpatient services stratified based on scores on STOP-BANG and ISNORED questionnaires. STPB = Stop-Bang. OSA is underdiagnosed and underreported in the general population, particularly in older adults4. Using the prospectively administered STOP-BANG and ISNORED questionnaires, we discovered that nearly 80% of hospitalized adults are at risk of sleep apnea. On a geriatric and a general medicine service, the proportions of persons at risk of OSA were higher than previously identified using the Berlin questionnaire5. Additionally, only 3 of 52 older adults had previously recognized sleep apnea, which underscores the concern that many older adults are undiagnosed before admission. All individuals with a major hospital adverse event were at risk of OSA. Limitations include a small sample size at a single academic center, possible selection bias given the low percentage of participants enrolled, and exclusion of individuals with cognitive impairment, a condition associated with OSA. Despite these limitations, our study demonstrated, that based on 2 prospective questionnaires, the prevalence of risk of OSA in hospitalized older adults is high. Further clarification of the burden of disease and optimal approaches to diagnosis and treatment of sleep apnea in this population is needed. Conflict of Interest: None of the authors have conflicts of interest to disclose. Author Contributions: Aaron Pickens was the lead researcher and manuscript author. Andrew Namen was the principle investigator and generated the initial concept for the project and supervised its completion. Karen Huang performed data analysis. Edward Haponik was integral in manuscript editing and revision. Daniel Forest, Richard Wyderski, Julie Williams, and William Hazzard provided guidance for the project and helped edit the manuscript. Sponsor's Role: There was no sponsorship for this study.

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