The silence of sleep disorders. High prevalence of insomnia and obstructive sleep apnea symptoms in chronic hepatitis C infection

Abstract

Introduction Fatigue is the leading patient reported symptom in chronic hepatitis C infection. Although the fatigue is recognized as an important patient reported outcome measure in hepatitis C research trials, it is rarely addressed in clinical settings. Sleep disorders are commonly associated with fatigue, yet the prevalence of specific sleep disorders and their contribution to fatigue in hepatitis C infection is unknown. The objective of this study was to determine the prevalence of clinical insomnia and obstructive sleep apnea and their association with fatigue in patients with hepatitis C infection treated at a tertiary liver clinic. Materials and methods Treatment seeking participants with chronic hepatitis C infection ( N =115; 36% females; mean age=56) were enrolled in a mixed design study on fatigue. Participants completed questionnaires on their fatigue, sleep, fatigue specific cognitions, depression and anxiety. Medical data were retrieved from hospital charts. Fatigue was assessed with the Fatigue Severity Scale (FSS), insomnia was assessed with the Insomnia Severity Index (ISI), excessive daytime sleepiness was measured with the Epworth Sleepiness Scale (ESS) and the risk for obstructive sleep apnea was determined with the STOP-BANG questionnaire. Results Almost 60 % of the total sample (56.9% of males and 64.3% of females) obtained a score indicating severe fatigue C related functional impairment (FSS i‘Ý 4). The median FSS score was 4.67 (interquartile range=2.92). More than one third of the sample (30.1% of males and 43% of females) scored above the ISI cut- off indicating moderate or severe clinical insomnia. Seventy-one percent of the sample (80.9% of males and 54.8% of females) scored at or above the cut-off score of 3 on the STOP-BANG questionnaire indicating a 70%- 86% likelihood of obstructive sleep apnea. Only 7% of the total sample had been diagnosed with sleep apnea. A one way ANOVA and post hoc tests indicated that participants with clinical insomnia only and those with a combination of clinical insomnia and potentially moderate/severe sleep apnea reported significantly higher fatigue than those without a clinically significant sleep problem or with a possible sleep apnea only. The mean ESS was above the cut-off for excessive daytime sleepiness only in the group with a combination of clinical insomnia and obstructive sleep apnea. Conclusion Clinically significant insomnia and obstructive sleep apnea Cseparately and in combination – may affect 50% of patients with chronic hepatitis C infection treated in tertiary liver centers. Obstructive sleep apnea is severely underdiagnosed and treated in this group. Patients with insomnia or a combination of insomnia and obstructive sleep apnea report the most severe fatigue related functional impairment. Excessive daytime sleepiness is not a sensitive marker of sleep disorders in this group, as only those with comorbid sleep disorders reported abnormal level of sleepiness. Screening for insomnia and obstructive sleep apnea and effective treatment of these disorders may alleviate the burden of fatigue of a significant proportion of patients with chronic hepatitis C infection.