A pictorial Sleepiness and Sleep Apnoea Scale to recognize individuals with high risk for obstructive sleep apnea syndrome.

PURPOSE: The aim of this study was to evaluate the validity of a new pictorial form of a screening test for obstructive sleep apnea syndrome (OSAS) - the pictorial Sleepiness and Sleep Apnoea Scale (pSSAS). Validation was performed in a sample of patients admitted to sleep clinics in the UK and Switzerland. PATIENTS AND METHODS: All study participants were investigated with objective sleep tests such as full-night-attended polysomnography or polygraphy. The pSSAS was validated by taking into account the individual result of the sleep study, sleep-related questionnaires and objective parameters such as body mass index (BMI) or neck circumference. Different scoring schemes of the pSSAS were evaluated, and an internal validation was undertaken. RESULTS: The full data set consisted of 431 individuals (234 patients from the UK, 197 patients from Switzerland). The pSSAS showed good predictive performance for OSAS with an area under the curve between 0.77 and 0.81 depending on which scoring scheme was used. The subscores of the pSSAS had a moderate-to-strong correlation with widely used screening questionnaires for OSAS or excessive daytime sleepiness as well as with BMI and neck circumference. CONCLUSION: The pSSAS can be used to select patients with a high probability of having OSAS. Due to its simple pictorial design with short questions, it might be suitable for screening in populations with low health literacy and in non-native English or German speakers.

The use of an online pictorial Epworth Sleepiness Scale in the assessment of age and gender specific differences in excessive daytime sleepiness.

BACKGROUND: Excessive daytime sleepiness (EDS) is a non-specific but highly prevalent cardinal symptom of sleep disorders. We hypothesized that with modern media and an online pictorial Epworth Sleepiness Scale (ESS) age and gender specific differences of EDS could be identified on a large scale. This could be helpful in the screening of patients with sleep disorders. PATIENTS AND METHODS: In 8,098 subjects, age and gender were recorded in addition to an online pictorial ESS (range 0-24 points). The cut-off for EDS (ESS >10 points) was chosen in line with the traditional ESS. RESULTS: The prevalence of EDS was slightly higher in male subjects (45% vs. 43%, P=0.033). When age was considered, female subjects tended to be sleepier in their 3(rd) and 4(th) lifetime decade (P=0.01 and P=0.003, respectively), whilst male subjects scored significantly higher in their 7(th) decade (P<0.0001); there was a trend to more daytime symptoms with higher age (P for trend <0.001). CONCLUSIONS: The online pictorial ESS identifies gender differences in EDS and reveals increased levels of sleepiness associated with higher age. The use of modern media facilitates reaching out to the general population to raise awareness of conditions associated with EDS such as sleep apnoea.

Developing a pictorial Epworth Sleepiness Scale.

OBJECTIVE: The Epworth Sleepiness Scale (ESS) was designed to be self-completed by the patient. However, it may not be understood by all, and unrecognised problems with literacy can impair the process. The ESS has been translated into a pictorial version for use in those with normal or diminished literacy skills. METHODS: An evaluation of the patients' ability to self-complete the ESS was undertaken in sleep and non-sleep respiratory clinics. Errors or problems encountered were recorded on a standard questionnaire. With the aid of a medical artist, pictorial representations of the eight ESS questions were developed and the new pictorial ESS was offered to patients alongside the traditional ESS. The two scales were compared for agreement with a kappa statistic, and patients were asked to record a preference for either the written or the pictorial scale. RESULTS: Evaluation of the traditional ESS showed that 33.8% (27/80) of ESS-naive patients made errors and 22.5% (18/80) needed help completing the questionnaire. The translated pictorial ESS showed good agreement with the traditional ESS on most questions; median kappa score 0.63, IQR 0.04. Fifty-five per cent reported a preference for the pictorial scale compared with the standard written ESS. Despite the fact that errors were frequently made on the traditional ESS, 96.8% of participants in the second study reported both scales to be easy to complete. More people (75.6%) reported the pictorial ESS to be very easy, in comparison with (64.6%) the worded ESS questionnaire. CONCLUSION: Errors are common when patients self-complete the traditional written ESS. Pictures with words have been shown to enhance the understanding and translation of medical information, and a pictorial translation of the ESS produces scores comparable with the traditional ESS and may be a suitable alternative for those with normal or diminished literacy.

Obstructive sleep apnea syndrome is associated with deficits in verbal but not visual memory.

RATIONALE: Although cognitive deficits are well documented in patients with sleep apnea, the impact on memory remains unclear. OBJECTIVES: To test the hypotheses that (1) patients with obstructive sleep apnea have memory impairment and (2) memory impairment is commensurate with disease severity. METHODS: Patients with obstructive sleep apnea and healthy volunteers (apnea-hypopnea index <5 events/h) completed a test battery specially designed to differentiate between aspects of memory (semantic, episodic, and working) versus attention. Sleepiness was measured on the basis of the Epworth Sleepiness Scale and Oxford Sleep Resistance test. Memory performance in patients versus control subjects was compared (Mann-Whitney U test; P < 0.01, Bonferroni corrected for multiple comparisons) and relationships between performance and disease severity were analyzed by linear regression. MEASUREMENTS AND MAIN RESULTS: Sixty patients and healthy control subjects matched for age (mean +/- SD: patients, 51 +/- 9 yr; control subjects, 50 +/- 9 yr) and education (patients, 14 +/- 3 yr; control subjects, 15 +/- 3 yr) participated. Patients demonstrated impaired Logical Memory Test results (immediate recall: patients, median [range], 36 [9-69]; control subjects, 43 [19-64], P = 0.0004; and delayed recall: patients, 22 [6-42]; control subjects, 27 [10-46]; P = 0.0001). There were minimal differences in attention, visual episodic, semantic, or working memory; patients performed better than control subjects on Spatial Span forward and backward. Regression analysis revealed that Logical Memory Test performance was not significantly related to disease severity after controlling for age, education, and sleepiness. CONCLUSIONS: Obstructive sleep apnea is associated with impairment in verbal, but not visual, memory. The impairment was present across a range of disease severity and was not explained by reduced attention. Such verbal memory impairment may affect daytime functioning and performance.

Health literacy in COPD.

If patients are to participate fully in their care and in the management of a long-term condition such as chronic obstructive pulmonary disease, good communication is essential. However, not all patients are able to use the written word and we need to be aware of the size of this problem and its implications for the way in which we give information and conduct medical consultations. The impact of health literacy on outcomes can be considerable and improvements can be made by being aware of the problem, offering information in several different forms, and by reinforcing the spoken word with pictorial images.

The determinants of therapeutic levels of continuous positive airway pressure in elderly sleep apnea patients.

We have examined the role of age on the continuous positive airway pressure (CPAP) levels required to treat two groups of elderly (n=70) and young (n=70) sleep apneic patients, matched for disease severity (apnea/hypopnea index), body mass index and neck circumference. Elderly patients required lower CPAP levels compared to young [mean (sd): 6.9(1.9)cm H(2)O and 9.4(3.5)cm H(2)O, respectively; P<0.0001]. To investigate this finding, we studied the effects of CPAP and its components (inspiratory and expiratory positive airway pressure) on lung volume and upper airway resistance in two groups of elderly [n=9, age 71.7(3.3) years] and young [n=9, age 36.7(4.4)] patients with sleep apnea during wakefulness. CPAP produced a greater decrease in airway resistance (P=0.009) and a greater increase in lung volume (P=0.008) in the elderly compared to young patients. We conclude that both the greater lung inflation and the greater direct splinting of the upper airway contributed to the lower CPAP level required by the elderly. Ageing may be an important determinant of therapeutic CPAP levels in clinical practice, especially in older sleep apneic patients.

Changes in brain morphology associated with obstructive sleep apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) causes hypoxemia and fragmented sleep, which lead to neurocognitive deficits. We hypothesised that focal loss of cortical gray matter generally within areas associated with memory processing and learning and specifically within the hippocampus would occur in OSA. METHODS: Voxel-based morphometry, an automated processing technique for magnetic resonance images, was used to characterise structural changes in gray matter in seven right handed, male patients with newly diagnosed OSA and seven non-apneic, male controls matched for handedness and age. RESULTS: The analysis revealed a significantly lower gray matter concentration within the left hippocampus (p=0.004) in the apneic patients. No further significant focal gray matter differences were seen in the right hippocampus and in other brain regions. There was no difference in total gray matter volume between apneics and controls. CONCLUSION: This preliminary report indicates changes in brain morphology in OSA, in the hippocampus, a key area for cognitive processing.