Undiagnosed Obstructive Sleep Apnea Is Independently Associated with Reductions in Quality

Undiagnosed obstructive sleep apnea is independently associated with reductions in quality of life in middle-aged, but not elderly men of a population cohort.

Sleep and Breathing

Sarah L. Appleton, Andrew Vakulin, R. Douglas McEvoy,Andrew Vincent, Sean A. Martin, Janet F. Grant , Anne W. Taylor, Nick A. Antic, Peter G. Catcheside, Gary A. Wittert, Robert J. Adams.

Corresponding author

Sarah L Appleton, The Health Observatory, Discipline of Medicine, University of Adelaide, The Queen Elizabeth Hospital Campus, Woodville Rd, Woodville, South Australia, 5011, Australia.

Email: ; Telephone: +61 8 8222 7349; Fax: +61 8 8222 6042

Online Resource Table 1. Comorbidity prevalence [% (n)] and mean (SD) SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores in relation to comorbidities and risk factors in men undergoing sleep studies.

Age 40-69 yrs (n=619) / Age ≥ 70 yrs (n=170)
PCS / MCS / PCS / MCS
% (n) / 50.4 (8.3) / 50.8 (9.0) / % (n) / 47.5 (10.5) / 50.5 (9.7)
BMI (Kg/m2)
≤ 24.9 / 20.6 (126) / 50.8 (8.0) / 50.8 (8.5) / 21.1 (35) / 48.9 (10.2) / 52.4 (8.2)
25.0-29.9 / 45.9 (281) / 51.4 (7.5) / 51.8 (8.2) / 49.4 (82) / 47.9 (10.5) / 50.9 (9.4)
≥ 30.0 / 33.5 (205) / 48.5c (9.4) / 49.2c (10.1) / 29.5 (49) / 46.3 (10.7) / 49.0 (11.0)
Smoking
Former/never / 80.9 (500) / 50.5 (8.3) / 51.0 (8.6) / 93.5 (159) / 47.9 (10.5) / 50.7 (9.7)
Current / 19.1 (118) / 50.0 (8.4) / 49.7 (10.1) / 6.5 (11) / 43.3 (11.2) / 47.8 (10.2)
No depression / 85.2 (513) / 51.7 (7.0) / 52.9 (6.2) / 88.7 (141) / 48.9 (9.5) / 52.4 (7.6)
Depression / 14.8 (89) / 43.5a (11.1) / 39.0a (12.4) / 11.3 (18) / 36.6a (12.9) / 36.4a (13.8)
No LUTS / 77.6 (469) / 51.0 (8.1) / 51.3 (8.8) / 64.0 (105) / 49.2 (10.1) / 52.2 (8.8)
LUTS / 22.4 (135) / 48.3a (8.9) / 48.9b (9.5) / 36.0 (59) / 44.9b (10.8) / 47.9b (10.7)
No ED / 86.1 (533) / 50.9 (7.8) / 51.2 (8.4) / 32.9 (56) / 52.8 (8.2) / 54.4 (6.9)
ED / 13.9 (86) / 46.9a (10.3) / 48.0b (11.7) / 67.1 (114) / 44.9a (10.6) / 48.7a (10.4)
No CVD / 94.7 (586) / 50.6 (8.2) / 50.8 (8.9) / 80.6 (137) / 48.5 (10.1) / 51.2 (9.4)
CVD / 5.3 (33) / 46.8b (10.1) / 49.4 (9.2) / 19.4 (33) / 43.5b (11.5) / 47.7 (10.6)
No diabetes / 86.3 (534) / 50.9 (7.9) / 51.0 (8.8) / 69.4 (118) / 48.3 (10.4) / 51.5 (8.7)
Diabetes / 13.7 (85) / 47.2a (10.2) / 49.4 (9.6) / 30.6 (52) / 45.8 (10.8) / 48.3 (11.5)
No hypertension / 51.6 (314) / 51.2 (7.5) / 50.8 (8.6) / 21.7 (36) / 48.9 (10.9) / 50.9 (8.7)
Hypertension / 48.4 (295) / 49.5 a (9.0) / 50.6 (9.4) / 78.3 (130) / 47.3 (10.4) / 50.6 (10.0)
Total cholesterol < 5.5 mmol/L / 57.4 (351) / 49.9 (8.9) / 50.9 (9.4) / 71.7 (119) / 46.6 (10.5) / 50.1 (9.6)
≥ 5.5 mmol/L / 42.6 (261) / 50.9 (7.6) / 50.4 (8.5) / 28.3 (47) / 50.1 (10.0) / 52.2 (10.0)

a p<0.01; b p<0.05; c p of differences between groups <0.05 by ANOVA

Abbreviations: BMI-Body mass index, LUTS- lower urinary tract symptoms, ED-erectile dysfunction, CVD-cardiovascular disease.

PCS and MCS scales are scored so that their means are set at 50 with a SD of 10.

For men aged 40-69 years, missing data occurred (<3%), thus for BMI n=612, depression n=602, LUTS n=604, hypertension n=609, total cholesterol n=612. The n for these variables in men aged ≥70 years (<6% missing) were n=166, 159, 164, 166, 166 respectively.

On-line Resource Table 2. Mean (SD) standardized SF-36 scale z-scores in relation to age and obstructive sleep apnea (OSA) and sleep-related parameters in men undergoing sleep studies.

Physical Functioning / Role Physical / Bodily Pain / General Health / Vitality / Social Functioning / Role Emotional / Mental Health
Age 40-69 yrs (n=633) / 0.08 (0.7) / 0.10 (0.9) / -0.12 (0.9) / -0.09 (0.9) / 0.01 (0.9) / 0.14 (0.9) / 0.18 (0.8) / 0.07 (0.9)
No OSA (AHI <10) / 0.18 (0.6) / 0.19 (0.7) / -0.02 (0.8) / 0.01 (0.8) / 0.11 (0.8) / 0.22 (0.7) / 0.23 (0.7) / 0.11 (0.8)
OSA (AHI ≥10) / -0.02a (0.8) / 0.01 (0.9) / -0.22b (1.0) / -0.19a (0.9) / -0.09a (1.0) / 0.06b (1.0) / 0.12 (0.9) / 0.02 (1.0)
Mild OSA (10-19) / 0.06 (0.7) / 0.11 (0.8) / -0.18 (1.0) / -0.12 (0.9) / -0.06 (1.0) / 0.09 (0.9) / 0.12 (0.9) / 0.01 (0.9)
Moderate OSA (20-29) / 0.08 (0.7) / 0.05 (0.9) / -0.13 (1.0) / -0.09 (0.8) / 0.06 (1.0) / 0.06 (1.0) / 0.15 (0.8) / 0.17 (0.9)
Severe OSA (≥30) / -0.36c (1.0) / -0.31c (1.1) / -0.41c (1.1) / -0.49c (1.0) / -0.34c (1.1) / -0.002 (1.1) / 0.07 (1.0) / -0.14 (1.1)
Difference: severe vs no OSA / 0.54 / 0.50 / 0.39 / 0.50 / 0.45 / 0.22 / 0.16 / 0.25
Epworth score ≤ 10 / 0.16 (0.7) / 0.17 (0.8) / -0.08 (0.9) / -0.05 (0.9) / 0.02 (0.9) / 0.18 (0.8) / 0.19 (0.8) / 0.09 (0.8)
Epworth score ≥ 11 / -0.08b (0.8) / -0.10a (0.9) / -0.39b (1.1) / -0.36a (0.9) / -0.31a (1.1) / -0.16a (1.0) / -0.05b (1.1) / -0.37a (1.1)
No depression / 0.14 (0.7) / 0.20 (0.7) / -0.01 (0.9) / 0.02 (0.8) / 0.17 (0.8) / 0.31 (0.6) / 0.34 (0.5) / 0.28 (0.7)
Depression / -0.25a (0.9) / -0.43a (1.1) / -0.67a (1.1) / -0.63a (0.9) / -0.82a (1.0) / -0.84a (1.2) / -0.75a (1.4) / -1.13a (1.1)
Age ≥ 70 yrs (n=177) / -0.49 (1.0) / -0.32 (1.1) / -0.24 (1.0) / -0.09 (0.9) / 0.12 (0.9) / 0.09 (1.0) / 0.14 (0.9) / 0.21 (0.9)
No OSA (AHI <10) / -0.48 (1.0) / -0.34 (1.1) / -0.27 (1.0) / -0.08 (0.9) / 0.11 (0.9) / 0.19 (0.9) / 0.29 (0.8) / 0.29 (0.8)
OSA (AHI ≥10) / -0.49 (1.0) / -0.32 (1.1) / -0.22 (1.0) / -0.10 (0.9) / 0.12 (1.0) / 0.04 (1.0) / 0.05a (1.0) / 0.17 (1.0)
Mild OSA (10-19) / -0.47 (1.0) / -0.14 (0.9) / -0.15 (1.0) / -0.08 (0.9) / 0.24 (0.9) / 0.16 (0.8) / 0.16 (0.8) / 0.31 (1.0)
Moderate OSA (20-29) / -0.37 (0.9) / -0.55 (1.0) / -0.31 (1.0) / -0.06 (0.9) / 0.10 (0.9) / 0.06 (0.8) / 0.07 (0.9) / 0.06 (0.9)
Severe OSA (≥30) / -0.63 (1.2) / -0.43 (1.3) / -0.27 (1.0) / -0.19 (1.0) / -0.09 (1.1) / -0.21 (1.3) / -0.20 (1.4) / -0.005 (1.0)
Difference: severe vs no OSA / 0.15 / 0.09 / 0.0 / 0.11 / 0.19 / 0.40 / 0.49 / 0.30
Epworth score ≤ 10 / -0.50 (1.0) / -0.34 (1.1) / -0.23 (1.0) / -0.09 (0.9) / 0.13 (0.9) / 0.15 (0.9) / 0.19 (0.9) / 0.26 (0.9)
Epworth score ≥ 11 / -0.63 (1.0) / -0.40 (1.1) / -0.41 (1.3) / -0.09 (1.0) / -0.05 (1.2) / -0.28 (1.3) / -0.15 (1.2) / -0.11(1.3)
No depression / -0.35 (0.9) / -0.20 (1.0) / -0.12 (1.0) / 0.06 (0.8) / 0.28 (0.8) / 0.27 (0.7) / 0.33 (0.6) / 0.38 (0.8)
Depression / -1.44a (1.4) / -1.15a (1.2) / -1.22a (1.0) / -1.04a (1.0) / -1.00a (1.0) / -1.16a (1.4) / -1.17a (1.6) / -1.18a (1.0)

a p<0.01, b p<0.05, c p of differences between groups <0.05 by ANOVA

Abbreviations: AHI- Apnea hypopnea index.

SF-36 scale scores are presented as standardized z scores, i.e. the number of standard deviations from the mean scale score of the population (e.g. z score of -1.0 or less equates to the lowest scoring 16% of the population).

On-line Resource Table 3. Age stratified linear regression analyses of the association of the apnea hypopnea index (AHI) with standardisedSF-36 scale scores in all MAILES participants and those free of depression.

Unstandardized B Coefficients (SE)
All men / Men without depression
Age ≥40 yrs
(n=789) / Age 40-69 yrs
(n=619) / Age ≥ 70 yrs
(n=170) / Age 40-69 yrs
(n=530) / Age ≥ 70 yrs
(n=152)
Physical Functioning / -0.003 (0.002) / -0.005b (0.002) / 0.002 (0.005) / -0.003 (0.002) / 0.010b (0.005)
Role Physical / -0.006 b (0.002) / -0.008a (0.003) / -0.001 (0.006) / -0.005b (0.002) / 0.006 (0.006)
Bodily Pain / -0.002 (0.002) / -0.003 (0.003) / 0.003 (0.005) / -0.002 (0.003) / 0.004 (0.005)
General Health / -0.004 b (0.002) / -0.006 b (0.002) / 0.001 (0.004) / -0.005b (0.003) / 0.004 (0.005)
Vitality / -0.005b (0.002) / -0.006 b (0.003) / -0.003 (0.004) / -0.005 (0.003) / 0.001 (0.005)
Social Functioning / -0.005b (0.002) / -0.003 (0.003) / -0.011b (0.005) / -0.002 (0.002) / -0.001 (0.005)
Role Emotional / -0.004 (0.002) / -0.001 (0.002) / -0.012b (0.004) / -0.002 (0.002) / 0.001 (0.004)
Mental Health / -0.003 (-0.002) / -0.003 (0.003) / -0.005 (0.005) / -0.001 (0.002) / 0.002 (0.005)

Coefficients reflect change in standardized SF-36 scale z scores per event increase in AHI. For example, the coefficient for Physical Functioning in men aged 40-69 (-0.005) represents a 0.05 SD reduction in score with per ten unit increase in AHI.

Models adjusted for age, body mass index, Epworth Sleepiness Scale scores, lower urinary tract symptoms, CVD, hypertension, diabetes, joint pain, sedative use, smoking, erectile dysfunction and depression (physical functioning, role physical, bodily pain, general health scores in all men only).

a Model B coefficient p<0.01, b Model B coefficient p<0.05

On-line ResourceFigure 1. Linear regression analysis of Physical Component Summary (PCS) and Mental Component Summary (MCS) scores against the Apnea Hypopnea Index (AHI) in men without depression aged 40-69 and ≥ 70 years.