Sleep Disorders - A Serious Public Health Issue

Mansoor Ahmed. M.D. F.C.C.P 
Director, Cleveland Sleep Center
Assistant Professor of Medicine & International Health, 
Case Western Reserve University, Cleveland, Ohio

" Blessing on him who first invented sleep It covers a man all over, thoughts and all like a cloak. It is meal for the hungry, drink for the thirsty, heal for cold, cold for the hot. It makes the shepherd equal 10 monarch and fool to wise.." Don Quixote

We spend 1/3 of our life time in state of sleep - Sleep affects our health in important ways.

The vast majority of Americans are severely sleep deprived as the result of demanding work schedule and various other life style factors. As result of sleep deprivation and other sleep disorders. sleepiness is extremely pervasive. Sleepiness has been identified as the cause of a growing number of transportation and industrial catastrophes with approximately 100,000 automobile accidents resulting in numerous fatalities and injuries every year. These sleep-health issues were vividly crystallized by the Chairman of National Commission on Sleep Disorder Research:

"What we are dealing with here are two gigantic problems for our society - An epidemic of undiagnosed and untreated sleep disorders; and pervasive sleep deprivation with all its consequences for errors, accidents, disability, damages and death".

Approximately 50 million American suffer from 80 identified Sleep Disorders including Snoring & Steep Apnea. Narcolepsy, Periodic Leg movements and conditions causing insomnia disorders. The impact of sleep disturbances on the health and welfare of our society rivals that of smoking. Obstructive sleep apnea (OSA), just 1 of several common sleep disorders, has a prevalence of 2-4% in middle aged adults, comparable with the prevalence of diabetes (1-2%), asthma (4% ) and the life time risk of colon cancer ( 5% ).

Similarly, insomnia is another common complaint affecting approximately 10 - 17% of the adult U.S. population. The total cost of insomnia, including treatment, lost productivity and insomnia-related accidents, may exceed $100 billion per year. Despite the epidemic proportion of such disorders, the overwhelming majority of the sleep disorder sufferers remain undiagnosed and untreated. Among several other reasons, one of it is due to the fact that the most of the physicians lack training in diagnosis and management of sleep disorders. Because of this, the current availability of sleep-health provision to patients with sleep disorders is based on a tertiary care, sub-specialty referral model, only a fraction of such patients are recognized and treated.

In 1990, the National Commission on sleep Disorders Research surveyed all 26 accredited US accredited medical schools, finding that on average only 2 hours of teaching in sleep physiology and sleep disorders occurs during entire 4-year curriculum. Sleep specialists have not done adequate job in designing sleep education initiative, involving primary care physicians so that they can offer sleep-health services at their clinical practices. 

"Exhortations to primary care physicians to diagnose and treat sleep disorders in ways which completely ignore the unique nature and special conditions of primary care clinical practice will perhaps will not succeed" states William C. Dement, M. D, who is one of the world leading sleep educationist and sleep disorders researcher. He proposed a unique solution for this problem, which involves the local, or community physicians in the case finding diagnostic testing and treatment of sleep disorders. 

In fact Dr William C. Dement applied this model, known as "The Walla Walla Project" to small community primary care set-up. As a part of the project, sleep disorders specia1ist provided a community with an education seminar, and 2-weekend courses in sleep disorders to local interested internists. The results of this project were a staggering success. Local sleep expertise was established and a large number of patients with sleep apnea were identified and treated in the community. The Walla Walla project can serve as practical model for the transfer of knowledge and technique from a traditional specialty care center to a community. Such a strategy for the diagnosis and treatment is necessary given the substantial prevalence of sleep disorders, limited availability of specialty evaluation (let alone the follow-up of patients who become diagnosed as having sleep disorders) and current lack of practicing physicians wined in sleep medicine.

Mindful of the facts that sleep disorders are very common and has a devastating effect on health, it is therefore prudent to include just 2 or 3 questions about sleep in HPI during an encounter at a primary care level. This simple practice principle will allow us to identify a large number of patients who may be suffering from serious sleep disorders. 

For example, simply inquiring about excessive daytime sleepiness and snoring or having trouble Calling asleep can be a clue to a serious disorder like sleep apnea or restless leg/periodic leg syndrome. Subsequently, simple algorithms can be established which provide initial management pathways for common sleep complaints i.e. simple sleep hygiene instruction should be the first step for a majority of patients with insomnia symptoms. With ongoing support and physician education program by a sleep specialist this initiative can lead to the successful detection and treatment of large number of patients with previously undiagnosed sleep disorders.

References: 
I: National Commission on sleep Disorders Research. Executive Summary and Executive Report. Bethesda MD: NIH, 1993 
2: Phillipson EA. Sleep Apnea: A major Public Health Problem. NEJM. 1993: 328: 1271-1273 
3: Kryger MH, Roth t. Dement WC eds. The Principles and Practice of Sleep Medicine. 2rd ed, 1994 
4: Ball Eric, M. Dement WC et al: Diagnosis and Treatment of Sleep Apnea Within \ Community: The Walla Walla Project. Arch Intern Med 1997,419-424 
5: Hauri, P.J; Esther M.S: Insomnia. Mayo Clinic Proceeding 65: 869-882, 1990.

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