Elsevier

Sleep Medicine

Volume 12, Issue 2, February 2011, Pages 142-146
Sleep Medicine

Original Article
Is the Berlin questionnaire a useful tool to diagnose obstructive sleep apnea in the elderly?

https://doi.org/10.1016/j.sleep.2010.09.004Get rights and content

Abstract

Objective

In the elderly, obstructive sleep apnea (OSA) is frequently under diagnosed. This study was undertaken to assess the accuracy of the Berlin questionnaire to diagnose OSA in a large healthy elderly population.

Patients and methods

Six hundred forty-three participants aged 65.6 years were examined. All subjects completed the Berlin questionnaire and underwent at-home respiratory recording. Presence of OSA was defined by an AHI > 15.

Results

Of the respondents, 202 subjects (31.4%) were in an OSA high-risk group according to the Berlin questionnaire. The high-risk subjects were significantly heavier, had greater waist and hip circumferences, higher AHI, and reported more frequently hypertension and diabetes. Habitual snoring was present in 54% of the sample, sleepiness in 12% of participants, and a BMI > 30 and a history of hypertension in 42.1%. Being in the high-risk group predicted an AHI > 15 with a sensitivity of 77%, a specificity of 39%, a positive predictive value of 63% and a negative predictive value of 55%. Among Berlin questionnaire categories, snoring correctly classified 61% of the sample and explained the 5% variance of AHI.

Conclusions

The Berlin questionnaire did not provide a high level of diagnostic specificity to discriminate OSA in an elderly population. Although not sufficiently accurate, this questionnaire can be used to identify subjects for sleep study assessment.

Introduction

Obstructive sleep apnea (OSA) is a common sleep disorder characterized by repetitive nocturnal respiratory airflow cessation, hypoxemia and sleep fragmentation, affecting 2–4% of middle-aged population [1], [2]. High prevalence rates of OSA were found in an elderly population (⩾65 years old) [3], 30.5% [4]–81% [5] having an apnea-hypopnea index (AHI)  5, and 39% of women and 51% of men having an AHI > 20 [5], [6]. Undiagnosed, and thus untreated, OSA is associated with severe morbidity and mortality essentially related to the OSA cardiovascular and cerebrovascular risk [6], [7], [8], [9], [10], [11].

Polysomnography is the gold standard diagnostic tool for assessing OSA, but only a minority of patients at risk of OSA have access to polysomnography, owing to its technical requirements, labor-intensive procedures and cost. Portable respiratory monitoring was recently introduced as a valid tool for diagnosis of OSA [12] in a clinical setting and in the elderly [13]. Despite being less complex than a full polysomnography, portable devices still entail a demanding examination and most sleep laboratories, already overburdened, are unable to diagnose all referred patients within a reasonable time. Moreover, from an epidemiological point of view, an efficient pre-selection procedure with an inexpensive and accurate method of screening, such as a questionnaire, can be conveniently incorporated for diagnostic purposes and follow-up studies to establish the still controversial question of hypertensive risk and vascular morbidity in elderly OSA patients.

The Berlin questionnaire [14] is a widely used screening tool in the clinical evaluation of OSA, identifying in a primary care population 37.5% of patients as being at high risk to have an AHI > 5, with a sensitivity and specificity of, 86% and 77%, respectively. The predictive performance of the Berlin questionnaire for OSA, however, may vary in different patient populations, the sensitivity ranging from 54% to 86% and the specificity from 43% to 77% [15], [16].

Although the Berlin questionnaire may be a useful tool in research and sleep medicine, it has never been validated in elderly subjects in whom the prevalence of OSA is significantly higher. The objective of the current study was to evaluate the Berlin questionnaire as a screening tool for OSA in a large generally healthy population and to assess which symptoms better predict OSA occurrence.

Section snippets

Subjects

Participants were from the PROOF study [17], a prospective cohort study of 1011 community-dwellers aged 65 years at the study entry, and randomly recruited from the electoral lists of the city of Saint-Etienne, France. An ancillary study addressing the association between OSA assessed by at-home polygraphic study and cardiovascular and cerebrovascular morbidity during a 7-year follow-up was proposed to participants (SYNAPSE study). The study methods have been reported previously [17], [18].

Statistical analyses

The subjects’ characteristics were summarized as means ± SEM for continuous variables, and counts and percentages for categorical variables. Comparisons between low-risk and high-risk groups were performed using the χ2-test for categorical variables and the t-Student test for continuous variables.

Sensitivity, specificity, positive and negative predictive values of the Berlin questionnaire were calculated for the whole sample, as well as for males and females, considering an AHI > 15 as the cutoff

Characteristics of the sample

A total of 643 subjects, 380 women and 263 men aged 65.6 ± 0.03 years were analysed. Their mean BMI was 25.3 ± 0.2 kg/m2 and their mean waist and hip circumference, respectively, 86.1 ± 10.4 cm and 98.1±.0.3 cm. The mean ESS score was 5.59 ± 0.2, 9% of subjects reporting daytime sleepiness. An AHI > 15 was identified in 369 (57.8%) subjects, 193 women and 176 men, males having a higher AHI (36.1 ± 1.9) compared to women (27.1 ± 1.9) (p < 0.001). The mean MMSE score was 28.7 ± 0.1, 10 having a value below 24 and 42

Discussion

Previous studies have underlined that OSA is a highly prevalent disorder in the elderly, carrying a high risk of cardiovascular morbidity and mortality. This study was the first attempt to assess the prevalence of individuals at high risk of having OSA in a community of elderly people using a validated questionnaire which has already been shown to have a very high sensitivity and specificity.

The first finding of our study was that, in line with recent data [25], [26], the Berlin questionnaire

Conflict of Interest

For all authors: no conflicts of interest and no financial interest and support for our activity.

Acknowledgments

This study was supported by a grant from the French Ministry of Health (Cellule Projet Hospitalier de Recherche Clinique National, Direction de la Recherche Clinique, CHU Saint-Etienne; Appel d’Offre 1998 and Appel d’Offre 2002) and by a grant from the “L’Association de Recherche SYNAPSE”.

References (39)

  • S. Ancoli-Israel et al.

    Morbidity, mortality and sleep-disordered breathing in community dwelling elderly

    Sleep

    (1996)
  • J.L. Kiely et al.

    Cardiovascular risk factors in patients with obstructive sleep apnoea syndrome

    Eur Respir J

    (2000)
  • A.S. Shamsuzzaman et al.

    Obstructive sleep apnea: implications for cardiac and vascular disease

    JAMA

    (2003)
  • H.K. Yaggi et al.

    Obstructive sleep apnea as a risk factor for stroke and death

    N Engl J Med

    (2005)
  • P.E. Peppard et al.

    Prospective study of the association between sleep disordered breathing and hypertension

    N Engl J Med

    (2000)
  • N.A. Collop et al.

    Portable monitoring task force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients

    J Clin Sleep Med

    (2007)
  • N.C. Netzer et al.

    Using the Berlin questionnaire to identify patients at risk for the sleep apnea syndrome

    Ann Intern Med

    (1999)
  • R.S. Strauss et al.

    Risk for obstructive sleep apnea

    Ann Intern Med

    (2000)
  • N. Ahmadi et al.

    The Berlin questionnaire for sleep apnea in a sleep clinic population: relationship to polysomnographic measurements of respiratory disturbances

    Sleep Breath

    (2008)
  • Cited by (55)

    • Sleep Quality in Neurodegenerative Diseases

      2020, Neurological Modulation of Sleep: Mechanisms and Function of Sleep Health
    • Sleep physiology and disorders in aging and dementia

      2019, Handbook of Clinical Neurology
      Citation Excerpt :

      Among categories defining a high OSA risk, sleepiness was less likely to be the determining factor for the high risk classification, snoring criteria alone showing a better sensitivity (63%) and specificity (59%) (Sforza et al., 2011). While this is not adequately sufficient to use in a general population, investigators still saw its value as a prescreening tool in a high risk older population (Sforza et al., 2011). The STOP-Bang Questionnaire (Chung et al., 2008) is another self-report questionnaire to identify individuals at risk for OSA.

    View all citing articles on Scopus
    View full text