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Sleeping next to someone with sleep apnea can have a significant impact on the quality of sleep and the health of both partners. The objective was to assess the emotional changes in the partners of patients with OSA. It is a comparative longitudinal study of 102 pairs of patients with a possible OSA diagnosis from January 2018 to October 2019. Female couples 85.7%. The mean age was 48.60 ± 8.99 for the couples. Emotional variables were analyzed through the HAD questionnaire (depression and anxiety), and we also included a Likert scale of the impact of OSA in couples created by the research team. The quality of life was evaluated with the SF-36 questionnaire. For the statistical processing and analysis of the data, the spss program was used. The conclusion was that couples after one year of CPAP treatment improvement in their mood. The results obtained suggest that treating the patient improves the quality of sleep for both.
Spanish Society of Pneumology and Thoracic Surgery (SEPAR), Madrid, Spain
*Address all correspondence to: isabelportelafer@hotmail.com
1. Introduction
Obstructive sleep apnea (OSA) is a major public health problem that, in its most serious forms, affects 3–6% of men and 2–5% of women [1, 2]. It causes arterial hypertension, increased risk of cardiovascular diseases, and deterioration of the quality of life of those who suffer from it and of those who live with the affected person [3, 4].
This pathology is characterized by the appearance of recurrent episodes of limitation of the passage of air during sleep, followed by awakening from subclinical sleep to return to normal breathing, leading to fragmented and poor-quality sleep, excessive daytime sleepiness, observed breathing interruptions, or awakenings due to gasping or choking in the presence of at least five obstructive respiratory events (apneas, hypopneas, or arousals related to respiratory effort) per hour of sleep. The presence of 15 or more obstructive respiratory events per hour of sleep in the absence of sleep-related symptoms is also sufficient for the diagnosis of OSA due to the greater association of this severity of obstruction with important consequences, such as increased risk of cardiovascular disease [5, 6, 7].
Daytime sleepiness is the most common manifestation of OSA. However, other common daytime effects include irritability, decreased concentration, memory impairment, decreased energy, and depressive symptoms [8]. Nocturnal symptoms include restlessness, diaphoresis, awakening with a sensation of suffocation or dyspnea, esophageal reflux, heartburn, laryngospasm, frequent nycturia, dry mouth, etc. Many studies have indicated an association between sleep apnea and cardiovascular/cerebrovascular disease-related morbidity and mortality. It has been associated with hypertension, coronary artery disease, congestive heart failure, arrhythmias, and stroke [9, 10, 11, 12, 13]. It has also been associated with increased mortality, with the most catastrophic result of daytime sleepiness being falling asleep behind the wheel and causing fatal car accidents [14].
The symptoms reported by the patient at night during their sleeping hours are normally witnessed by the partner as snoring, apnea, micro-arousals, and nycturia [15, 16]. Thus, breaking not only his own circadian rhythm but also that of his companion. Specifically, snoring, present in 35–45% of men and close to a quarter of women, often motivates the couple themselves to request a medical visit for the patient.
Recently, studies have confirmed that the impact of OSA on patients’ perceived quality of life (HRQoL) is widespread, affecting physical health outcomes (negative health perceptions, increased bodily pain, and poor physical functioning) and psychosocial functioning (e.g., mood disturbance, poor academic performance) [17]. Indeed, there are many domains of life that remain unexplored in the sleep laboratory. For such cases, Lacasse et al., have defined four key domains of HRQoL: somatic sensation, physical function, emotional state, and social interaction [18]. Since physiological measures alone cannot be taken as surrogate markers of HRQoL, this emphasizes the need to measure it directly [19].
The diagnosis of this disease is made by polysomnography (PSG), which includes neurophysiological and cardiorespiratory variables or, failing that, given its high cost, respiratory polygraphy (RP) to identify respiratory events through O2 saturation, nasobuccal flow, and respiratory effort in order to classify the severity of the disease [20, 21].
General measures to curb OSA include weight loss and reeducation of body position. Several studies have shown that initial weight loss decreases the number of apneas-hypopneas and can even make the symptoms disappear by reducing lung volume [22, 23]. A total of 50% of patients have longer and more frequent apneas when sleeping in the supine position; these decrease the collapsibility of the nasopharynx and improve significantly in lateral decubitus [24].
Continuous positive pressure (CPAP) is the first line of treatment, that is, the gold standard, indicated mainly in patients with moderate to severe OSA. It consists of a turbine that transmits a predetermined pressure through a nasal or facial mask adapted to the subject’s face and fixed with a harness, thus closing the circuit. In this way, an authentic “pneumatic splint” is produced that transmits positive pressure to the entire upper airway (UPA) and prevents its collapse, both static (apneas) and dynamic (hypopneas) during sleep. The adjustment of the CPAP level must be individualized in each patient through a PSG or through a validated auto-CPAP system [25, 26]. This treatment can reduce respiratory disorders and daytime sleepiness and improve quality of life [27]; it also reduces the risk of traffic accidents [28] and seems to normalize blood pressure (BP) figures in a relevant percentage of hypertensive subjects with OSA.
Among the effects of sleeping next to someone who suffers from OSA, the following three stand out:
Sleep disturbances: The snoring and breathing pauses associated with sleep apnea can disturb a partner’s sleep, leading to difficulty falling asleep and staying asleep.
Emotional exhaustion: Lack of sleep can lead to irritability and emotional exhaustion in the bed partner, which can affect the relationship.
Worry and anxiety: Sleep apnea can be a worrisome condition for a partner, who may feel anxious about their loved one’s health and well-being. The levels of anxiety experienced by someone sleeping next to a person with sleep apnea can vary depending on individual circumstances and the severity of the sleep disorder [29].
To assess the emotional changes in the partners of patients with OSA after one year of CPAP use.
2.2 Secondary objective
Analyze the impact that OSA has on the quality of life of those who suffer from it and their partner; considering variables such as the impact on sleep, daytime sleepiness, and the level of satisfaction in the intimate sphere. Likewise, we want to know if the use of CPAP by the patient improves their symptoms and that of their partner in the short, medium, and long term.
Comparative longitudinal study, n = 104, study with 52 patients with obstructive sleep apnea and their partners at the Álvaro Cunqueiro Hospital in Vigo, Spain. Patients received CPAP therapy for one year (2018–2019). We analyzed physical, mental, and sexual changes with validated questionnaires: SF-36 (for quality of life), HAD (for depression and anxiety), and CSFQ (for sexual variables). We also use a Likert scale created by our research team to assess the impact on their partners.
3.1 Subjects of study
The recruitment was carried out in the Pneumology Service of the Integrated Management Organizational Structure (EOXI) of Vigo, which covers an area of 600,000 inhabitants. In this area is the largest hospital in Galicia, Hospital Álvaro Cunqueiro, which, in turn, is the headquarters of the Galicia Sur Health Research Institute (IISGS), with which we collaborate to develop this project (http://novohospitalvigo.sergas.es/Paxinas/Portada.aspx) and which combines assistance, teaching, and translational research in the health area of Vigo.
To carry out this study, it will be necessary to recruit patients diagnosed with SAHS and their partners. The set of participants will be recruited from patients who attend the sleep respiratory disorders consultations of the Pneumology Service of the Álvaro Cunqueiro Hospital in Vigo.
The criteria for the inclusion of patients are: (1) age > 18 years and > 65 years, (2) diagnosis of OSA, (3) share rest with your partner, (4) not present other neurological or psychiatric pathologies or a history of head trauma, (5) in women, not being pregnant or lactating, (6) not consume toxins that can affect the results, (7) sign the Informed Consent and, (8) patients with complete consciousness (full authority to participate in the study and grant the informed consent).
The criteria for excluding patients are: (1) comorbidity with another serious diagnosis or concomitant disease that could interfere and (2) the presence of neuromuscular disorders that affect the respiratory pattern or cycle.
The patients’ partners will be invited to participate when they accompany their partners to the consultation. If they agree to participate, they will cover, date, and sign the informed consent.
As criteria for the inclusion of patients in the second phase after starting positive pressure therapy, it was necessary to use it for no less than 4 hours per day on average.
The sample size has been determined considering previous studies referring to the study of quality of life in patients with OSA. For OSA patients, the mean Epworth sleepiness scale (ESS) decreased from 12.9 +/− 4.4 to 7.3 +/− 4.0 after CPAP treatment. For bed partners, mean SES decreased from 7.4 +/− 6.1 to 5.8 +/− 4.7. Mean SF-36 scores were significantly reduced in both patients and bed partners. Significant improvements were observed in the subjects in the role domains: physical, vitality, social functioning, emotional role, and mental health. In bed partners, significant changes were observed on the SF-36 in the domains of physical function, vitality, social functioning, and mental health. If we consider these standard deviations to detect differences in mean HRQoL scores of four points, assuming a confidence level of 95% and a statistical power of 80%, we obtain a sample size of 51 patients in each group for a total of 102 subjects.
3.2 Data analysis
The different variables collected in the questionnaires will be studied, looking for possible associations between the clinical variables and sociodemographic variables. In this way, we consider intervariable interactions that may determine the interpretation of the results. The possible correlations existing between the scores of the AHI, snore and quality of life.
For data analysis, the statistical program SPSS for Windows version 20.0 will be used. This part will be carried out with advice from the IBI Statistics Unit. The Kolmogorov-Smirnov test (Lilliefors modification) will be used to verify the normality of the variables, the student’s t-test and the Mann-Whitney U statistic to compare the differences between means with independent data, and the Spearman correlation index and regression line. Categorical variables will be expressed as percentages and will be compared using the chi-square test.
3.3 Benefits, applicability, validity, and limitations
With this project, we are interested in knowing the perception of our patients with OSA and that of their partners before and after receiving treatment with CPAP, regarding the changes they perceive in the quality of life in order to better understand the educational and psychological needs that both have. In this way, we can provide them with the best comprehensive assistance possible. Normally, we focus only on the person who suffers from this disease, but according to the reviewed bibliography, its consequences can have a very negative effect on the health of the roommate, although there are still few scientific studies on the subject.
It is expected to demonstrate that in parallel to the improvement in the patient’s symptoms, the quality of life of their partner will also improve, reducing anxiety, and problems in intimate relationships.
Various self-report instruments have been used to assess the impact of OSA on HRQoL: the SF-36 health questionnaire, the life satisfaction scale, the Nottingham health profile, and the 28-item general health questionnaire. Since these instruments are generic, their ability to detect subtle effects of the disease on the quality of life and the effects caused by various treatment modalities led to the development of specific questionnaires for the OSA, such as the sleep apnea quality of life index (SAQLI), the functional sleep impact questionnaire (FOSQ), the obstructive sleep apnea severity index, and the Epworth sleepiness scale. The American Thoracic Society and the American Sleep Disorders Association have made reviews of the use and properties of these instruments; however, none of the mentioned organizations has issued recommendations on the use of specific CVRS instruments due to the lack of comparative data. In a study, the SAQLI was more sensitive to the changes in the quality of life in patients. For the OSA that the SF-36 has a strong content and a constructive validity, but it has to be administered by an interview. Sexual function is addressed only in the FOSQ and OSAPOSI. Aspects related to work are evaluated specifically and in detail mainly by the OSAPOSI, while leisure activities are evaluated in depth by the FOSQ. On the other hand, all the instruments evaluate various aspects of interpersonal interactions and relationships with the exception of the OSAPOSI, which includes only three items limited to marital and sexual relationships.
We developed a study to investigate the impact of OSA and its treatment with CPAP on the quality of life of the patient and their partner, where it affects so that a complete therapy can be planned that meets the specific needs of the patient. Any treatment modality chosen on the basis of disturbances in physiological parameters is unlikely to be complete as these parameters may not be the true representative of the magnitude of suffering in SAHS patients. Therefore, there is a need for a comprehensive holistic treatment that considers the physiological, emotional, and social impairment of the individual patient.
As limitations, the lack of a control group to avoid observation bias stands out.
Variables and questionnaires used.
Variables of the sociodemographic questionnaire:
Age.
Sex.
Civil status.
Country of birth.
Education level.
Socioeconomic level.
Employment situation (Shifts).
Toxic consumption.
Variables of the clinical questionnaire:
BP
Weight and height
BMI
Neck perimeter
AHI
Presence of ACVA, ischemic cardiopathy, heart failure, COPD, rhinitis, psychiatric disorders, and other diseases.
Symptoms of respiratory disorder during sleep.
Questionnaire on sleep quality during the nocturnal PLG study.
Assessment of sleepiness: excessive daytime sleepiness (Epworth sleepiness scale).
Functional impact of sleep questionnaire (FOSQ).
SF-36 health questionnaire.
Scale of anxiety and depression (HAD).
The Epworth sleepiness scale is a short Likert-type questionnaire that attempts to determine cministered test in which the investigated subject is asked about the frequency (or probability) of falling asleep on an increasing scale that goes from 0 to 3, for eight different everyday situations, in which most people may be involved, in their daily life, although not necessarily every day. The score of the eight situations is added to obtain a total number. A result between 0 and 9 is considered normal, while one between 10 and 24 indicates that the patient should be referred to a specialist. For example, a score between 11 and 15 indicates the possibility of mild to moderate sleep apnea, while a score of 16 and above indicates the possibility of severe sleep apnea or narcolepsy.
The FOSQ questionnaire was specifically designed to measure the impact that primary or secondary excessive sleepiness disorders have on daily functioning. The instrument is based on the concept of functional status, that is, the daily behavioral performance in the physical, psychological, and social areas. The FOSQ is made up of 30 items that make up five domains: (a) activity level, (b) surveillance, (c) intimacy and partner relationships, (d) general productivity, and (e) socialization level. You have four response options: 0 (I do not do this activity for other reasons), 1 (yes, extremely), 2 (yes, moderately), 3 (yes, little), and 4 (no).
The SF-36 health questionnaire is made up of 36 questions (items) that assess both positive and negative states of health. The questionnaire covers eight scales, which represent the health concepts most frequently used in the main health questionnaires, as well as the aspects most related to the disease and treatment. The 36 items of the instrument cover the following scales: Physical function, physical role, bodily pain, general health, vitality, social function, emotional role, and mental health. Additionally, the SF-36 includes a transition item that asks about the change in the general state of health compared to the previous year. This item is not used for the calculation of any of the scales but provides useful information on the perceived change in health status during the year prior to the administration of the SF-36.
The HAD scale has 14 items and was designed for the evaluation of anxiety and depression in nonpsychiatric outpatient hospital services. It is a state measure with two scales, one for anxiety and one for depression. One of its main virtues is the suppression of somatic symptoms so that they can be evaluated independently of the underlying somatic disease.
In the baseline sample, 85.7% of the patients were male. Mean age in patients is 47.6 +/− 4.2 and in couples 48.6 +/− 8.9. AHI: 41.3 +/− 27.6. (52% severe).
In the social function (SF), role emotional (RE), and mental health (MH) dimensions of the SF-36, the average score was lower in couples than in patients (p < 0.03, p < 0.05, and p < 0.03, respectively).
In the physical function (PF), physical role (PR), general health (GH), and vitality (V) dimensions, the average score was lower in patients than in their partners (p < 0.05, p < 0.01, p < 0.02, and p < 0.02, respectively) (Figure 1).
Figure 1.
Classification of patients according to severity of AHI.
The total score in the questionnaire for changes in sexual function (SF) was lower in the couple (p < 0.02).
Quality of life is as affected in patients with OSA as in their partners, although in different dimensions. The couples show a greater alteration in the emotional, social, and sexual sphere, while the patients perceive greater affectation in the physical plane.
Group of patients: The AHI showed a statistically significant correlation, positive for the HAD questionnaire, and negative for the SF-36 questionnaires.
Group of couples: The correlation is found in snoring, positive for HAD and negative for the SF-36 questionnaires. In addition to a positive (moderate) correlation with the level of symptoms reported by the patient (r = 0.424; p < 0.01) (Table 1).
Variable
HAD
SF-36
Patients
AHI
P < 0,05 R = 0,237
P < 0,02 R = −0,309
Couples
Snore
P < 0,03 R = 0,298
P < 0,01 R = −0,396
Table 1.
Pearson correlation analysis for the HAD and SF-36 questionnaires of OSA patients and bed partners.
After one year of CPAP therapy by the patients, the partners showed lower levels of anxiety and depression compared to the previous year (P < 0.001). Items related to quality of life (physical functioning, limitation due to physical problems, discomfort, social role, mental health, limitation due to emotional problems, vitality, and general perception of health) showed significant improvement.
Ninety percent of members reported that CPAP has significantly improved the health of patients and 85% stated that the use of CPAP has had a beneficial impact on their own health status.
An adequate understanding and comprehension on the part of the patient and partner about the type of disease they are facing can be a great support to ensure correct adherence to treatment with CPAP, the studies carried out by Cartwright reflected this [30]. It is also of great importance to maintain a healthy relationship to have an open dialog about rest, even if it means doing it separately on certain occasions so as not to interfere with the other’s sleep [31].
Fatigue-inducing conditions, such as sleep loss, compromise these factors, leading to decline in decision performance. Aidman et al., using a 40-hour sleep deprivation protocol, examined these factors and the resulting decision performance. Thirteen Australian Army male volunteers (aged 20–30 years) were tested at multiple time points on psychomotor vigilance, inhibitory control, task switching, working memory, short-term memory, fluid intelligence, and decision accuracy and confidence in a medical diagnosis-making test. Assessment took place in the morning and night over two consecutive days, during which participants were kept awake. Consistent with previous work, cognitive performance declined after a night without sleep. Extending previous findings, self-regulation and self-monitoring suffered significantly greater declines immediately after the sleepless night. These results indicate that the known decline in complex decision-making performance under fatigue-inducing conditions might be facilitated by metacognitive rather than cognitive mechanisms [32].
The Meta-analysis conducted by Natan et al. indicates that sleep deprivation, whether total or not, leads to a significant increase in state anxiety levels, but sleep restriction does not. Regarding the effect of the length of the period of sleep deprivation, no significant results were observed, but there was a notable tendency for an increase in anxiety in longer sleep deprivations. With regard to tools, the state-trait anxiety inventory (STAI) seems to be the best one to measure sleep-induced anxiogenesis, while the profile of mood states (POMS) presented inconclusive results [33].
In the pediatric field Smirni et al. found interesting results on how this pathology affects the quality of life of mothers, the authors concluded that “the child respiratory disease, with its sudden and unpredictable features, appeared as a significant source of stress for the mother”. Such stress condition may have an impact on mothers’ personality traits (self-esteem, locus of control) and on their memory performances [34]. On the other hand, Operto FF et al. concluded that children with sleep apnea have fewer emotional intelligence skills than children who do not suffer from this clinical condition, which considerably affects the response to stress and decision-making [35].
Adherence to treatment is an essential condition for proper compliance. As CPAP is a chronic treatment, and due to its special characteristics, the percentage of patients who abandon the therapy or who decide not to use it from the beginning is not negligible. According to some studies, from 5 to 50% reject treatment or interrupt it on the first night/week of its use, while abandonment at 5 years stands at 23% (although we can find figures as diverse as 4–46%, most in the first year) [36].
It is essential to understand that anxiety levels can vary from person to person, and sleep apnea is a medical disorder that requires proper care and treatment. If the bed partner is experiencing elevated levels of anxiety due to sleep apnea, it is important to seek medical support and consider options to improve the situation, such as seeking sleep apnea treatment or considering temporarily separate bedrooms. Emotional support and open communication are also critical in addressing any worries or concerns related to shared sleep disorder.
The impact on the quality of life of patients with OSA without CPAP treatment depends on the AHI, while in their partners their snoring is the determining factor.
After one year of treatment, the couples showed a decrease in anxiety and depression variables, as well as an increase in all areas of quality of life, including libido. It can be affirmed that CPAP treatment improves the general state of health of both the patient and the couple, that is the reason why we can conclude that treating one improves the sleep quality of both.
I thank Dr. Alberto Fernandez Villar for his support in presenting this work to the Ethics Committee. Thanks to Dr. Mar Mosteiro for always believing in me. Thanks to Tania Baltanas for her support with the statistical analysis.
Thank you to each couple who participated in the project.
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Written By
Isabel Portela Ferreño
Submitted: 21 July 2023Reviewed: 26 July 2023Published: 31 October 2023
Open access peer-reviewed chapter
