0
Original Research: SLEEP MEDICINE |

Prevalence of Symptoms and Risk of Sleep Apnea in the US Population*: Results From the National Sleep Foundation Sleep in America 2005 Poll FREE TO VIEW

David M. Hiestand, MD, PhD; Pat Britz, MEd, MPM; Molly Goldman, BA; Barbara Phillips, MD, MSPH, FCCP
Author and Funding Information

*From the Division of Pulmonary, Critical Care, and Sleep Medicine (Drs. Hiestand and Phillips), University of Kentucky College of Medicine, Lexington, KY; the National Sleep Foundation (Ms. Britz), Washington, DC; and WB&A Market Research (Ms. Goldman), Annapolis, MD.

Correspondence to: David M. Hiestand, MD, PhD, K528 Kentucky Clinic, Division of Pulmonary, Critical Care, and Sleep Medicine, 740 South Limestone St, Lexington, KY 40536-0028; e-mail: Dmhies00@email.uky.edu



Chest. 2006;130(3):780-786. doi:10.1378/chest.130.3.780
Text Size: A A A
Published online

Background: Obstructive sleep apnea (OSA) is a common medical condition with significant adverse consequences, but OSA remains undiagnosed in many individuals. The Berlin questionnaire is a validated instrument that is used to identify individuals who are at risk for OSA.

Design: We conducted an analysis of data from the Sleep in America 2005 Poll of The National Sleep Foundation (NSF). The NSF poll is an annual telephone interview of a representative sample of US adults.

Participants: The 2005 NSF poll included 1,506 adults. The mean age of participants was 49 years (775 were women).

Measurements: The Berlin questionnaire was embedded in the NSF poll. This instrument includes questions about snoring, witnessed apneas, self-reported hypertension, and daytime sleepiness. Height and weight were included for the calculation of body mass index (BMI). The NSF poll included detailed demographic information and extensive questions related to all aspects of sleep.

Results: Of the 1,506 respondents, 26% (31% of men and 21% of women) met the Berlin questionnaire criteria indicating a high risk of OSA. The risk of OSA increased up to age 65 years. A significant number of obese individuals (57%) were at high risk for OSA. Those whose Berlin questionnaire scores indicated a high risk for OSA were more likely to report subjective sleep problems, a negative impact of sleep on quality of life, and a chronic medical condition than those who were at lower risk.

Conclusions: As many as one in four American adults could benefit from evaluation for OSA. Considering the serious adverse health and quality-of-life consequences of OSA, efforts to expedite diagnosis and treatment are indicated.

Figures in this Article

Obstructive sleep apnea (OSA) is a common medical condition with serious adverse consequences. The most significant medical consequences include increased risk of hypertension,12 coronary vascular disease,3congestive heart failure,4cerebrovascular disease,5glucose intolerance,6and impotence.7Severe, untreated OSA has recently been linked to increased cardiovascular mortality.810 In addition to its contribution to medical disease, untreated OSA can cause daytime somnolence, cognitive impairment, loss in work productivity, and increased risk of automobile crashes.1113

The prevalence of OSA in the United States is currently estimated to be between 5% and 10%.1415 It is estimated that only 10% of the population has been adequately screened for appropriate diagnosis.16 This estimate is based on the prevalence of risk factors for OSA in the population. The at-risk population, however, is much larger, and the means to appropriately screen patients remains to be accurately defined.

One screening tool is the Berlin questionnaire, which is a simple instrument that has been studied in primary care settings.1718 This instrument is used to classify subjects who are at high risk and low risk for OSA by identifying snoring behavior, daytime sleepiness, obesity, and hypertension. This tool has reasonable sensitivity, specificity, and positive predictive value in a primary care population. For example, in a study of 744 adult respondents, 37.5% were identified as being at high risk by the application of the Berlin questionnaire.17 A subset of 100 of these 744 respondents underwent portable polysomnography, and were identified as being at high risk when the results of the Berlin questionnaire predicted a respiratory disturbance index (RDI) of > 5 with a sensitivity of 0.86, a specificity of 0.77, a positive predictive value of 0.89, and a likelihood ratio of 3.79. In a study of 8,000 primary care patients from the United States and Europe, 32% had a high pretest probability for OSA19 based on the Berlin questionnaire.

The purpose of this analysis was to assess the prevalence of individuals who were at risk for OSA in a broad sample of the US population, using the Berlin questionnaire. We further characterized the population at high risk for OSA in terms of their responses to general questions about sleep and self-reported concomitant medical conditions.

Data pertaining to the prevalence of those at risk for sleep apnea in this report are from the 2005 National Sleep Foundation (NSF) annual Sleep in America poll. The NSF is an independent nonprofit organization that is dedicated to improving public health and safety by achieving an understanding of sleep and sleep disorders, and by supporting education, sleep-related research, and advocacy (www.sleepfoundation.org). Established in 1990, the NSF relies on voluntary contributions as well as grants from foundations, corporations, government agencies, and other organizations to support its programs. The NSF conducts Sleep in America polls annually, with the release of the results timed to coincide with National Sleep Awareness Week, which is the week before the change to Daylight Savings Time in the spring. The topics and questions included in the poll are selected by a subset of volunteers, staff, and board members, and there is no commercial or industry influence on this poll. Some topics and questions are maintained from year to year in order to assess trends over time.

The 2005 poll included questions regarding sleep and sleep habits. Since the diagnosis of OSA can be suspected with a high degree of likelihood on the basis of history and anthropometric data,2023 we deemed it possible and appropriate to learn about the prevalence and risks of this cluster of symptoms in a survey of sleep habits. The instrument included to evaluate risk of OSA was the Berlin questionnaire. The Berlin questionnaire was developed in 1996. It has been previously validated in a community survey, which was used in conjunction with portable monitoring.18 In that study, the questionnaire was found to predict an RDI of > 5 with a sensitivity of 0.86, a specificity of 0.77, a positive predictive value of 0.89, and a likelihood ratio of 3.79.

The content of the Berlin questionnaire has been previously described in detail.17 Briefly, the questionnaire is divided into three sections. In section 1, respondents are asked whether they snore. Those who respond affirmatively are asked how loud the snoring is, how often it occurs, and whether their snoring bothers other people. Respondents are also asked whether anyone has ever noticed the cessation of breathing during sleep. In section 2, respondents are asked how often they feel tired or fatigued after sleep, how often they feel tired, fatigued, or not up to par during wake time, and whether they ever fall asleep driving a car. In section 3, respondents are asked about a personal history of hypertension, as well as their height, weight, age, and sex. Body mass index (BMI) is calculated from the information in section 3. A section is considered positive if there are two affirmative answers in either section 1 or 2, or one affirmative response in section 3. Individuals who have positive scores in two of the three sections are considered to be at risk for OSA. The version of the Berlin questionnaire that was used in this study is included in the Appendix.

In the 2005 NSF poll, a variety of other information about sleep, sleep habits, lifestyle, and illnesses were collected. Individuals were also asked whether they felt they had a sleep problem. For the purposes of the poll, symptoms of sleep problems were defined as follows: (1) having difficulty falling asleep; (2) waking a lot during the night; (3) waking up too early and not being able to get back to sleep; (4) waking up feeling unrefreshed; (5) snoring; (6) unpleasant feelings in the legs; or (7) experiencing pauses in breathing. Respondents were also asked whether they had ever been told by a doctor that they had the following medical conditions (yes, no): heart disease; high BP; arthritis; diabetes; lung disease; heartburn or gastroesophageal reflux disease; anxiety disorder; or depression.

A random sample of telephone numbers was purchased, and quotas were established by region and age, based on household data from the US Census. The total sample size was designed to be 1,500 participants. Telephone interviews were conducted between September 20 and November 7, 2004, resulting in a random sample of 1,506 adults. The interviews averaged 20 min in duration. In order to qualify for inclusion in the survey, participants had to be community-dwelling (eg, not residing in institutions), ≥ 18 years of age, and living within the continental United States. Interviewers explained the poll to participants by reading a script that said, “I am calling on behalf of the NSF to conduct a survey about sleep among Americans. This is not a sales call; it is a national research survey. It will take a few minutes of your time and your responses will be kept strictly confidential.” A total of 26,847 households were called; 4,343 did not answer repeated phone calls, and 4,168 potential participants refused to participate. Thus, the participation rate calculated by taking the number of completed interviews divided by the number of completed interviews plus the number of contacted households who refused participation or did not qualify was 23%. Response rates did not vary by region of the country. Institutional review board approval is not required to conduct or publish the results of a poll without any individual identifying information that is conducted by a nonprofit independent organization. There was no compensation for participation.

Approximately 80% of the interviewing was conducted on weekdays between 5:00 pm and 8:00 pm, on Saturdays between 10:00 am and 4:00 pm, and on Sundays between 4:00 pm and 8:00 pm by professional interviewers from WB&A Market Research (Annapolis, MD) on behalf of the NSF.

The characteristics of the sample are listed in Table 1 . This sample included a similar number of men (n = 731; 49%) and women (n = 775; 51%). The mean age was 49 years. Most reported having a partner, with 62% married, 33% single, and 5% living with someone (“partnered”). Geographic distribution was consistent with the US population, as follows: 36% lived in the South; 21% lived in the West; 24% lived in the Midwest; and 19% lived in the Northeast. The race/ethnicity of the sample included 84% who described themselves as white/white and 16% who described themselves as minority/other. A majority (52%) were employed full-time, and, of those, 80% worked regular day shifts.

The total poll sample represented the US population in terms of BMI and chronic medical conditions (Table 1). Of the 1,506 respondents, 895 (59%) reported snoring. Of those who snored, 54% did so ≥ 3 nights per week, and 40% did so every night or almost every night. Most snorers reported that their snoring has bothered others. Witnessed pauses in breathing were strikingly common, with 96 respondents (6%) reporting witnessed pauses on ≥ 3 nights per week. The presence of witnessed pauses was found almost exclusively in those individuals who were found to have a high risk according to the Berlin questionnaire score (88 of 96 respondents; 92%), but it was found in only 23% of persons in this group.

Sleepiness symptoms were common in the population. A total of 387 persons (26%) reported waking feeling tired or fatigued on ≥ 3 days of the week. This symptom was much more common in the high-risk group determined by the Berlin questionnaire results, having been reported by 244 persons (63%) in this group. Nearly a fifth of all respondents (272; 18%) reported being late to work due to a sleep problem. This finding was slightly more common in those with a high-risk Berlin questionnaire score (25% vs 16% of those with low risk). Alarmingly, 478 respondents (32%) reported driving drowsy one or more times per month. This finding was more common in those with a high-risk Berlin questionnaire score (48% vs 26%, respectively).

The risk of OSA as determined by Berlin questionnaire score increased linearly with increasing age, as shown in Figure 1 . Nineteen percent of those persons 18 to 29 years of age were at high risk as were 25% of those 30 to 49 years of age, and 33% of those 50 to 64 years of age. The risk declined after the age of 65 years, with 21% of persons in this older group defined as being at high risk. In the group of persons 18 to 29 years of age, high risk was equally distributed between men and women. In all other age groups, however, more men than women were identified as being at high risk based on Berlin questionnaire score.

Overall, 31% of men were in the high-risk group compared to 21% of women (p ≤ 0.001). Snoring (≥ 3 nights per week) was also more common in men, occurring in 19% vs 13% of women (p ≤ 0.001). Similarly, witnessed apneas (≥ 3 nights per week) were reported by 4% of men vs 2% of women (p ≤ 0.01).

Obesity strongly predicted the Berlin questionnaire score (Fig 2 ). Among obese individuals (ie, BMI ≥ 30 kg/m2), 59% had a high-risk Berlin questionnaire score. Those individuals with a low BMI (ie, < 20 kg/m2) had a negligible relative risk (RR) of a high-risk score at 0.2% (95% confidence interval [CI], 0.03 to 1.50%). The RR increased with BMI class, with those with a BMI of 25 to 30 kg/m2 having an RR of 1.63 (95% CI, 1.18 to 2.24), those with a BMI of 30.1 to 40 kg/m2 having an RR of 5.38 (95% CI, 4.08 to 7.12), and those with a BMI of > 40 kg/m2 having an RR of 7.11 (95% CI, 5.25 to 9.64).

The presence of any chronic medical condition was also associated with a high-risk Berlin questionnaire score. Overall, those persons reporting a chronic medical illness (identified above) were more likely to have a high-risk Berlin questionnaire score (35% vs 11% of those with a low-risk score).

The most striking finding of this study was that one in four individuals of a representative sample of US adults appears to be at high risk for OSA. In 1993, the classic Wisconsin Sleep Cohort Study reported that 4% of men and 2% of women cohort met what the investigators called “minimal diagnostic criteria” for OSA, defined as an apnea-hypopnea index (AHI) of > 5 events per hour that was associated with daytime hypersomnolence.24This value appears repeatedly in the current literature. In this same cohort, however, 9% of women and 24% of men had an AHI of ≥ 5 events per hour, and 44% of men and 28% of women were habitual snorers. Subsequent to this widely quoted study, the US population has aged and become more obese. The risk of significant sleep-disordered breathing rises both with BMI25 and with age.15

In addition to the fact that the risk factors for sleep apnea are increasing in the general population, the diagnostic criteria for sleep apnea continue to evolve, which results in a shifting metric, making prevalence hard to estimate. In an exhaustive review of currently available data, Young and colleagues15 revisited the prevalence of sleep apnea, and estimated that 5% of adults in Western countries have sleep apnea syndrome with sleepiness and an unknown fraction have sleep-disordered breathing without overt sleepiness. However, even that estimate is probably an underestimate. For example, the Sleep Heart Health Study26 reported that 22% of 1,824 people had an RDI of ≥ 15 events per hour, which most practitioners would consider to be significant sleep apnea. This cohort had a mean age of 65 years, and a mean RDI of 10.9 events per hour of sleep. In a study of sleep apnea incidence, the Cleveland Family Study14 of 285 individuals without significant sleep apnea at baseline demonstrated that the incidence of the development of sleep-disordered breathing (AHI, ≥ 5 events per hour) is about 7% per year, and the incidence of the development of an AHI of > 15 events per hour is about 2% per year. In this study, 47 of 286 eligible participants (16%; 95% CI, 13 to 21%) had a second-study AHI of at least 10, and 29 participants (10%; 95% CI, 7 to 14%) had a second-study AHI result of at least 15. (The authors skirted the issue of what constitutes OSA syndrome, referring instead to “sleep-disordered breathing” or to absolute AHIs). The Cleveland Family Study14 also suggested that with aging, male gender and BMI become less important as risk factors for OSA. Of note, Brazilian investigators27 applied the Berlin questionnaire to 10,101 truck drivers and reported that 26% were at high risk for OSA.

We found a bell-shaped relationship between age and high risk for sleep apnea (Fig 1), with a declining risk after the age of 65 years. Some previous work15,2829 indicates that the risk of sleep apnea increases linearly with aging, but other data3031 have demonstrated a decline after mid-life. In general, studies of clinical populations have tended to find a peak prevalence of clinically significant sleep-disordered breathing in middle age, but population-based studies have found increasing levels of sleep-disordered breathing with aging. One possible explanation for this discrepancy has been suggested by Bixler et al30 as follows: “Severity of sleep apnea, as indicated by both number of events and minimum oxygen saturation, decreased with age when any sleep apnea criteria were used and when controlling for BMI. The study shows that the prevalence of sleep apnea tends to increase with age but that the clinical significance (severity) of apnea decreases.” This notion is supported by recent work from Lavie et al,9 who found that all-cause mortality for a given severity of sleep apnea was greater for men < 50 years of age than those > 50 years of age. In other words, describing “severity” of sleep apnea by the simplified metric of the apnea-hypopnea index does not reliably capture the severity of hypoxemia, the duration of events, associated cardiac arrhythmias, and degree of sleep disruption that may be associated.

The 2005 NSF poll did not include a representative sampling of ethnic groups currently present in the United States despite efforts to do so. Only 16% of the sample reported here was nonwhite. This is an unfortunate problem with telephone polls and is also a problem with much of the published literature about sleep apnea prevalence to date. To the extent that the poll sample underestimated the true ethnic representation in this country, it may also underestimate the prevalence of sleep apnea. Ethnicity appears to play a role in the development of sleep-disordered breathing. Asian,3234 African-American,3536 and Hispanic25 individuals may be at increased risk for sleep apnea, even when controlling for other important risk factors. Another weaknesses is that the height and weight data were self-reported (as were all of the data), and could be inaccurate. This, unfortunately, is a problem common to all telephone interviews.

The 2005 NSF poll indicates that one in four Americans is at high risk for OSA, with increasing risk up to the age of 65 years. Considering the serious adverse health and quality-of-life consequences of sleep-disordered breathing, efforts to expedite diagnosis and treatment are urgently needed.

Berlin Questionnaire

The following questions were asked in the course of the telephone survey. Responses were recorded and section sums tallied. If two or more sections were positive, the individual was considered the have a high-risk Berlin score.

Section 1

  • Do you snore?

    • Yes (1)

    • No (0)

    • Don’t know/refused (0)

  • If you snore, your snoring is:

    • Slightly louder than breathing (0)

    • As loud as talking (0)

    • Louder than talking (0)

    • Very loud; can be heard in adjacent rooms (1)

    • Don’t know/refused (0)

  • How often do you snore?

    • Nearly every day (1)

    • 3 to 4 nights per week (1)

    • 1 to 2 nights per week (0)

    • 1 to 2 nights per month (0)

    • Never or nearly never/don’t know (0)

  • Has your snoring ever bothered other people?

    • Yes (1)

    • No/don’t know/refused (0)

  • Has anyone noticed that you quit breathing during your sleep?

    • Nearly every day (2)

    • 3 to 4 times a week (2)

    • 1 to 2 times a week (0)

    • 1 to 2 times a month (0)

    • Never or nearly never/don’t know/refused (0)

    • Add scores from questions 1 to 5:

    • If ≥ 2, check here

Section 2

  • How often do you feel tired or fatigued after your sleep?

    • Nearly every day (1)

    • 3 to 4 times a week (1)

    • 1 to 2 times a week (0)

    • 1 to 2 times a month (0)

    • Never or nearly never/don’t know/refused (0)

  • During your wake time, do you feel tired, fatigued, or not up to par?

    • Nearly every day (1)

    • 3 to 4 times a week (1)

    • 1 to 2 times a week (0)

    • 1 to 2 times a month (0)

    • Never or nearly never/don’t know/refused (0)

  • Have you ever nodded off or fallen asleep while driving a vehicle?

    • Yes (1)

    • No/don’t know/refused (0)

  • If yes, how often does it occur?

    • Nearly every day (1)

    • 3 to 4 times a week (1)

    • 1 to 2 times a week (0)

    • 1 to 2 times a month (0)

    • Never or nearly never/don’t know/refused (0)

    • Add scores from questions 6 to 9:

    • If ≥ 2, check here

  • Do you have high BP?

    • Yes (1)

    • No (0)

    • Don’t know/refused (0)

  • What is your height?

  • What is your weight?

  • How old are you?

  • Are you

    • Male?

    • Female?

  • Body mass calculation (by interviewer)

    • Is BMI > 30 kg/m2? i. Yes (1) ii. No (0)

    • Add scores from questions 10 to 15:

    • If ≥ 1, check here

    • If ≥ 2 sections are checked, subject is at risk for sleep apnea (ie, high-risk Berlin score).

Abbreviations: AHI = apnea-hypopnea index; BMI = body mass index; CI = confidence interval; NSF = National Sleep Foundation; OSA = obstructive sleep apnea; RDI = respiratory disturbance index; RR = relative risk

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Table Graphic Jump Location
Table 1. Demographic and Anthropometric Characteristics of the 2005 Sleep in America Poll Respondents (n = 1,506)
Figure Jump LinkFigure 1. Prevalence of positive Berlin questionnaire scores by age for men and women.Grahic Jump Location
Figure Jump LinkFigure 2. Prevalence of positive Berlin questionnaire scores by BMI.Grahic Jump Location
Figure Jump LinkFigure 3. Prevalence of chronic illnesses among individuals with high-risk Berlin questionnaire score. Individuals were asked, “Have you ever been told by a doctor that you have any of the following medical conditions… ”Grahic Jump Location
Nieto, FJ, Young, TB, Lind, BK, et al (2000) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study.JAMA283,1829-1836. [CrossRef] [PubMed]
 
Peppard, PE, Young, T, Palta, M, et al Prospective study of the association between sleep-disordered breathing and hypertension.N Engl J Med2000;342,1378-1384. [CrossRef] [PubMed]
 
Peker, Y, Hedner, J, Norum, J, et al Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up.Am J Respir Crit Care Med2002;166,159-165. [CrossRef] [PubMed]
 
Kaneko, Y, Floras, JS, Usui, K, et al Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea.N Engl J Med2003;348,1233-1241. [CrossRef] [PubMed]
 
Yaggi, HK, Concat, J, Kernan, WN, et al Obstructive sleep apnea as a risk factor for stroke and death.N Engl J Med2005;343,2034-2041
 
Babu, AR, Herdegen, J, Fogelfeld, L, et al Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea.Arch Intern Med2005;165,447-452. [CrossRef] [PubMed]
 
Goncalves, MA, Guilleminault, C, Ramos, E, et al Erectile dysfunction, obstructive sleep apnea syndrome, and nasal CPAP treatment.Sleep Med2005;6,333-339. [CrossRef] [PubMed]
 
Campos-Rodriguez, F, Pena-Grinan, N, Reyes-Nunez, N, et al Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure.Chest2005;128,624-633. [CrossRef] [PubMed]
 
Lavie, P, Lavie, L, Herer, P All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age.Eur Respir J2005;25,514-520. [CrossRef] [PubMed]
 
Marin, JM, Carrizo, SJ, Vicente, E, et al Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study.Lancet2005;365,1046-1053. [PubMed]
 
Engelman, HM, Martin, SE, Dreary, IJ, et al Effect of CPAP therapy on daytime function in patients with mild sleep apnoea/hypopnoea syndrome.Thorax1997;52,114-119. [CrossRef] [PubMed]
 
Turkington, PM, Sircar, M, Saralaya, D, et al Time course of changes in driving simulator performance with and without treatment in patients with sleep apnoea hypopnoea syndrome.Thorax2004;59,56-59. [PubMed]
 
George, CF Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP.Thorax2001;56,508-512. [CrossRef] [PubMed]
 
Tishler, PV, Larkin, EK, Schluchter, MD, et al Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing.JAMA2003;289,2230-2237. [CrossRef] [PubMed]
 
Young, T, Peppard, PE, Gottlieb, DJ Epidemiology of obstructive sleep apnea: a population health perspective.Am J Respir Crit Care Med2002;165,1217-1239. [CrossRef] [PubMed]
 
Young, T, Evans, L, Finn, L, et al Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.Sleep1997;20,705-706. [PubMed]
 
Netzer, NC, Stoohs, RA, Netzer, CM, et al Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.Ann Intern Med1999;131,485-491. [PubMed]
 
Netzer, NC, Hoegel, JJ, Loube, D, et al Prevalence of symptoms and risk of sleep apnea in primary care.Chest2003;124,1406-1414. [CrossRef] [PubMed]
 
Crocker, BD, Olson, LG, Saunders, NA, et al Estimation of the probability of disturbed breathing during sleep before a sleep study.Am Rev Respir Dis1990;142,14-18. [PubMed]
 
Flemons, WW, Whitelaw, WA, Brant, R, et al Likelihood ratios for a sleep apnea clinical prediction rule.Am J Respir Crit Care Med1994;150,1279-1285. [PubMed]
 
Kushida, CA, Efron, B, Guilleminault, C A predictive morphometric model for the obstructive sleep apnea syndrome.Ann Intern Med1997;127,581-587. [PubMed]
 
Maislin, G, Pack, AI, Kribbs, NB, et al A survey screen for prediction of apnea.Sleep1995;18,158-166. [PubMed]
 
Rowley, JA, Aboussouan, LS, Badr, MS The use of clinical prediction formulas in the evaluation of obstructive sleep apnea.Sleep2000;23,929-938. [PubMed]
 
Young, T, Palta, M, Dempsey, J, et al The occurrence of sleep-disordered breathing among middle-aged adults.N Engl J Med1993;328,1230-1235. [CrossRef] [PubMed]
 
Kripke, DF, Ancoli-Israel, S, Klauber, MR, et al Prevalence of sleep-disordered breathing in ages 40–64 years: a population-based survey.Sleep1997;20,65-76. [PubMed]
 
Gottlieb, DJ, Whitney, CW, Bonekat, WH, et al Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study.Am J Respir Crit Care Med1999;159,502-507. [PubMed]
 
Moreno, CR, Caravalho, FA, Lorenzi, C, et al High risk for obstructive sleep apnea in truck drivers estimated by the Berlin questionnaire: prevalence and associated factors.Chronobiol Int2004;21,871-879. [CrossRef] [PubMed]
 
Duran, J, Esnaola, S, Rubio, R, et al Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.Am J Respir Crit Care Med2001;163,685-689. [PubMed]
 
Ancoli-Israel, S, Kripke, DF, Klauber, MR, et al Sleep-disordered breathing in community-dwelling elderly.Sleep1991;14,486-495. [PubMed]
 
Bixler, EO, Vgontzas, AN, Ten Have, T, et al Effects of age on sleep apnea in men: I. Prevalence and severity.Am J Respir Crit Care Med1998;157,144-148. [PubMed]
 
Lavie, P, Herer, P, Peled, R, et al Mortality in sleep apnea patients: a multivariate analysis of risk factors.Sleep1995;18,149-157. [PubMed]
 
Li, KK, Powell, NB, Kushida, C, et al A comparison of Asian and white patients with obstructive sleep apnea syndrome.Laryngoscope1999;109,1937-1940. [CrossRef] [PubMed]
 
Ip, MSM, Tsan, WT, Lam, WK, et al Obstructive sleep apnea syndrome: an experience in Chinese adults in Hong Kong.Chin Med J (Engl)1998;111,257-260. [PubMed]
 
Kim, J, In, K, Kim, J, et al Prevalence of sleep-disordered breathing in middle-aged Korean men and women.Am J Respir Crit Care Med2004;170,1108-1113. [CrossRef] [PubMed]
 
Stepanski, E, Zayyad, A, Nigro, C, et al Sleep-disordered breathing in a predominantly African-American pediatric population.J Sleep Res1999;8,65-70
 
Redline, S, Tishler, PV, Hans, MG, et al Racial differences in sleep-disordered breathing in African-Americans and Caucasians.Am J Respir Crit Care Med1997;155,186-192. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Prevalence of positive Berlin questionnaire scores by age for men and women.Grahic Jump Location
Figure Jump LinkFigure 2. Prevalence of positive Berlin questionnaire scores by BMI.Grahic Jump Location
Figure Jump LinkFigure 3. Prevalence of chronic illnesses among individuals with high-risk Berlin questionnaire score. Individuals were asked, “Have you ever been told by a doctor that you have any of the following medical conditions… ”Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Demographic and Anthropometric Characteristics of the 2005 Sleep in America Poll Respondents (n = 1,506)

References

Nieto, FJ, Young, TB, Lind, BK, et al (2000) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study.JAMA283,1829-1836. [CrossRef] [PubMed]
 
Peppard, PE, Young, T, Palta, M, et al Prospective study of the association between sleep-disordered breathing and hypertension.N Engl J Med2000;342,1378-1384. [CrossRef] [PubMed]
 
Peker, Y, Hedner, J, Norum, J, et al Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up.Am J Respir Crit Care Med2002;166,159-165. [CrossRef] [PubMed]
 
Kaneko, Y, Floras, JS, Usui, K, et al Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea.N Engl J Med2003;348,1233-1241. [CrossRef] [PubMed]
 
Yaggi, HK, Concat, J, Kernan, WN, et al Obstructive sleep apnea as a risk factor for stroke and death.N Engl J Med2005;343,2034-2041
 
Babu, AR, Herdegen, J, Fogelfeld, L, et al Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea.Arch Intern Med2005;165,447-452. [CrossRef] [PubMed]
 
Goncalves, MA, Guilleminault, C, Ramos, E, et al Erectile dysfunction, obstructive sleep apnea syndrome, and nasal CPAP treatment.Sleep Med2005;6,333-339. [CrossRef] [PubMed]
 
Campos-Rodriguez, F, Pena-Grinan, N, Reyes-Nunez, N, et al Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure.Chest2005;128,624-633. [CrossRef] [PubMed]
 
Lavie, P, Lavie, L, Herer, P All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age.Eur Respir J2005;25,514-520. [CrossRef] [PubMed]
 
Marin, JM, Carrizo, SJ, Vicente, E, et al Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study.Lancet2005;365,1046-1053. [PubMed]
 
Engelman, HM, Martin, SE, Dreary, IJ, et al Effect of CPAP therapy on daytime function in patients with mild sleep apnoea/hypopnoea syndrome.Thorax1997;52,114-119. [CrossRef] [PubMed]
 
Turkington, PM, Sircar, M, Saralaya, D, et al Time course of changes in driving simulator performance with and without treatment in patients with sleep apnoea hypopnoea syndrome.Thorax2004;59,56-59. [PubMed]
 
George, CF Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP.Thorax2001;56,508-512. [CrossRef] [PubMed]
 
Tishler, PV, Larkin, EK, Schluchter, MD, et al Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing.JAMA2003;289,2230-2237. [CrossRef] [PubMed]
 
Young, T, Peppard, PE, Gottlieb, DJ Epidemiology of obstructive sleep apnea: a population health perspective.Am J Respir Crit Care Med2002;165,1217-1239. [CrossRef] [PubMed]
 
Young, T, Evans, L, Finn, L, et al Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.Sleep1997;20,705-706. [PubMed]
 
Netzer, NC, Stoohs, RA, Netzer, CM, et al Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.Ann Intern Med1999;131,485-491. [PubMed]
 
Netzer, NC, Hoegel, JJ, Loube, D, et al Prevalence of symptoms and risk of sleep apnea in primary care.Chest2003;124,1406-1414. [CrossRef] [PubMed]
 
Crocker, BD, Olson, LG, Saunders, NA, et al Estimation of the probability of disturbed breathing during sleep before a sleep study.Am Rev Respir Dis1990;142,14-18. [PubMed]
 
Flemons, WW, Whitelaw, WA, Brant, R, et al Likelihood ratios for a sleep apnea clinical prediction rule.Am J Respir Crit Care Med1994;150,1279-1285. [PubMed]
 
Kushida, CA, Efron, B, Guilleminault, C A predictive morphometric model for the obstructive sleep apnea syndrome.Ann Intern Med1997;127,581-587. [PubMed]
 
Maislin, G, Pack, AI, Kribbs, NB, et al A survey screen for prediction of apnea.Sleep1995;18,158-166. [PubMed]
 
Rowley, JA, Aboussouan, LS, Badr, MS The use of clinical prediction formulas in the evaluation of obstructive sleep apnea.Sleep2000;23,929-938. [PubMed]
 
Young, T, Palta, M, Dempsey, J, et al The occurrence of sleep-disordered breathing among middle-aged adults.N Engl J Med1993;328,1230-1235. [CrossRef] [PubMed]
 
Kripke, DF, Ancoli-Israel, S, Klauber, MR, et al Prevalence of sleep-disordered breathing in ages 40–64 years: a population-based survey.Sleep1997;20,65-76. [PubMed]
 
Gottlieb, DJ, Whitney, CW, Bonekat, WH, et al Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study.Am J Respir Crit Care Med1999;159,502-507. [PubMed]
 
Moreno, CR, Caravalho, FA, Lorenzi, C, et al High risk for obstructive sleep apnea in truck drivers estimated by the Berlin questionnaire: prevalence and associated factors.Chronobiol Int2004;21,871-879. [CrossRef] [PubMed]
 
Duran, J, Esnaola, S, Rubio, R, et al Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.Am J Respir Crit Care Med2001;163,685-689. [PubMed]
 
Ancoli-Israel, S, Kripke, DF, Klauber, MR, et al Sleep-disordered breathing in community-dwelling elderly.Sleep1991;14,486-495. [PubMed]
 
Bixler, EO, Vgontzas, AN, Ten Have, T, et al Effects of age on sleep apnea in men: I. Prevalence and severity.Am J Respir Crit Care Med1998;157,144-148. [PubMed]
 
Lavie, P, Herer, P, Peled, R, et al Mortality in sleep apnea patients: a multivariate analysis of risk factors.Sleep1995;18,149-157. [PubMed]
 
Li, KK, Powell, NB, Kushida, C, et al A comparison of Asian and white patients with obstructive sleep apnea syndrome.Laryngoscope1999;109,1937-1940. [CrossRef] [PubMed]
 
Ip, MSM, Tsan, WT, Lam, WK, et al Obstructive sleep apnea syndrome: an experience in Chinese adults in Hong Kong.Chin Med J (Engl)1998;111,257-260. [PubMed]
 
Kim, J, In, K, Kim, J, et al Prevalence of sleep-disordered breathing in middle-aged Korean men and women.Am J Respir Crit Care Med2004;170,1108-1113. [CrossRef] [PubMed]
 
Stepanski, E, Zayyad, A, Nigro, C, et al Sleep-disordered breathing in a predominantly African-American pediatric population.J Sleep Res1999;8,65-70
 
Redline, S, Tishler, PV, Hans, MG, et al Racial differences in sleep-disordered breathing in African-Americans and Caucasians.Am J Respir Crit Care Med1997;155,186-192. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543