Original ArticleIs the Berlin questionnaire a useful tool to diagnose obstructive sleep apnea in the elderly?
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”.
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