(Chest. 2003;124:2209-2214.)
© 2003
American College of Chest Physicians
Impact of Nasal Continuous Positive Airway Pressure Therapy on the Quality of Life of Bed Partners of Patients With Obstructive Sleep Apnea Syndrome*
Liam S. Doherty, MB;
John L. Kiely, MD;
Geraldine Lawless and
Walter T. McNicholas, MD, FCCP
* From the Respiratory Sleep Disorders Unit, St. Vincent’s University Hospital, Dublin, Ireland.
Correspondence to: Walter McNicholas, MD, FCCP, Department of Respiratory Medicine, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland; e-mail: walter.mcnicholas{at}ucd.ie
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Abstract
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Background: Continuous positive airway pressure (CPAP) improves daytime sleepiness and quality of life in patients with obstructive sleep apnea syndrome (OSAS). However, few studies have examined the impact of treatment on the quality of life of bed partners of these patients.
Methods: We prospectively studied 55 couples in which one person (the patient) had OSAS diagnosed and was subsequently commenced on CPAP therapy; 45 of these couples shared a bed on a regular basis. Both partner and patient completed postal questionnaires immediately prior to CPAP therapy and again after a median of 8 weeks (interquartile range [IQR], 6 to 12 weeks) of therapy at home. Questionnaires consisted of the Epworth sleepiness scale (ESS), the UK Short Form-36 health survey, and the hospital anxiety and depression scale. No intervention or advice was given to the partner of the patient receiving CPAP therapy.
Results: In addition to the expected significant benefits reported by patients receiving CPAP, bed partners also reported significant improvements in ESS scores (median, 4 [IQR, 1 to 8.5] before CPAP; median, 2 [IQR, 1 to 5] during CPAP), in addition to measures of anxiety, role limitation due to physical problems, role limitation due to emotional problems, social functioning, mental health, and energy/vitality (all p < 0.05 by Wilcoxon-signed rank testing).
Conclusions: These data support the hypothesis that partners of patients with OSAS benefit significantly from the CPAP therapy their bed partners receive.
Key Words: continuous positive airway pressure • hospital anxiety depression scale • obstructive sleep apnea syndrome • partner • Short-Form 36
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Introduction
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Obstructive sleep apnea syndrome (OSAS) affects between 1% and 4% of the adult population in various epidemiologic studies,1
2
3
4
depending on the study population and the diagnostic criteria used. Typical nocturnal symptoms include loud snoring, restless sleep, and witnessed apneas, which may disturb the sleep of the bed partner, often to the point of having to sleep apart. Therapy for moderate and severe forms of the disorder usually consists of nasal continuous positive airway pressure (CPAP), which is very effective but requires continuous nightly use of the device.5
Since CPAP machines are cumbersome and may be regarded as noisy, this therapy has the potential for adverse effects on the bed partner. Thus, the overall impact of CPAP on the partner will likely reflect a balance between the beneficial effects related to control of snoring and sleep apnea and the potentially detrimental effects of the device itself.
Bed partners frequently prompt the referral of patients with OSAS because their own sleep is disturbed by the patients’ snoring and restless sleep. McArdle and co-workers6
reported significant impairment in sleep quality among partners of patients with OSAS but did not find any improvement in objective sleep quality after treatment with CPAP. We have previously reported beneficial effects on the quality of life of bed partners of OSAS patients successfully treated with CPAP,7
but this study was retrospective and used a nonstandardized questionnaire. Therefore, we performed a prospective study, administering identical standardized questionnaires to OSAS patients and their partners before and after treatment with CPAP. The principal study aim was to confirm our previous retrospective findings that CPAP improves the quality of life of partners when CPAP is administered to patients with OSAS.
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Materials and Methods
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Consecutive patients with partners were considered for inclusion who had documented OSAS on overnight sleep studies performed in our sleep disorders unit, and who were booked for initiation of CPAP therapy. Patients were required to have an apnea-hypopnea index (AHI) of at least five apneas and/or hypopneas per hour, with excessive daytime sleepiness as determined by an Epworth sleepiness scale (ESS) score 
9.8
We excluded patients or partners who had other medical disorders or were receiving medications that might be expected to influence sleep quality. All sleep studies were attended and lasted a minimum of 7 h, and were performed overnight in our hospital-based sleep laboratory with either an Oxford Medilog SAC847 polysomnography system (Oxford Instruments, Oxford, UK) or an Autoset limited diagnostic system (ResMed Ltd; Abington, UK). An experienced sleep technician manually reviewed all sleep studies. We have demonstrated good correlation between these two systems in a previous report.9
CPAP titration was performed using the Autoset device set in the treatment mode,10
and patients were prescribed a pressure that controlled 90% of apneas, hypopneas, and flow-limited breaths. All patients were prescribed a fixed-pressure CPAP device. We excluded patients who failed to tolerate or did not accept CPAP at the time of initial titration. Patients who reported not sharing a bed with their partners on the initial questionnaire were analyzed separately.
Questionnaires
Patients and partners who satisfied the prestudy selection criteria were each invited by mail to participate and, if agreeable, to separately complete standardized questionnaires relating to quality of life before commencing CPAP therapy and again after 6 weeks of continuous therapy. These consisted of the Short-Form 36 (SF-36),11
12
13
the hospital anxiety and depression scale (HADS) scale,14
the ESS,15
and a general questionnaire requesting information such as snoring habits, alcohol consumption, and sharing the bedroom. The SF-36 (UK-SF36; Health Services Research Unit, University of Oxford; Oxford, UK) is a standardized quality-of-life questionnaire that is a well-validated and sensitive measure of health status in the general population, and consists of 36 questions that evaluate the respondent’s perception of their performance in eight dimensions of daily life. The HADS is a 14-item scale designed to provide a brief state measure of both anxiety (7 items) and depression (7 items) without contamination of scores by physical symptomatology. The ESS is a validated subjective score that measures the level of daytime sleepiness.
Statistical Analysis
Numerical data are expressed as median (interquartile range [IQR]). Differences between groups were analyzed using the Mann-Whitney U test if data were not normally distributed, and the Student t test if normally distributed. Differences within groups were calculated using the Wilcoxon signed-rank test. Correlations were calculated using the Pearson correlation coefficient; p < 0.05 was considered significant, and an intention-to-treat analysis was performed.
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Results
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Eighty-two patients and partners who fulfilled the prestudy selection criteria were invited to participate, of whom 18 couples did not respond at all, and a further 9 couples were excluded on the basis of the patient failing to tolerate CPAP on the initial titration. Ten couples reported not sharing a bed and slept in a separate room on a regular basis, and these were analyzed separately. A further six partners who satisfied the inclusion criteria and completed the initial questionnaires failed to complete the follow-up questionnaire despite repeated reminders. These six couples were included in the analysis on an intent-to-treat basis. The 37 patients who did not participate were excluded or analyzed separately, and were on average younger than the remaining 45 patients, but had no difference in body mass index (BMI), AHI, or ESS score (Table 1
). There was no difference between patients with diagnoses by polysomnography or Autoset limited diagnostic system in terms of OSAS severity (median AHI, 52/h [IQR, 28.2 to 53.6/h] vs 30.3/h [IQR, 19.7 to 61.4/h], respectively, p = 0.6) or CPAP compliance (median, 7 h per night [IQR, 6.5 to 8] vs 7 h per night [IQR, 6 to 8/h], p = 0.7).
Follow-up questionnaires were sent out after 6 weeks of therapy and were returned after an average of 8 weeks (IQR, 6 to 12 weeks) of CPAP therapy. Patients reported that they used the device an average of 7 h per night (IQR, 6 to 8 h per night); but since not all CPAP machines had a built-in time clock, it was not possible to objectively verify compliance. Baseline demographic and clinical details on patients and partners are given in Table 2
. Patients were almost exclusively male, middle-aged, and most had severe OSAS. There was no significant change in weight, alcohol consumption, or smoking habit on follow-up review in either patient or partner.
Both patients and partners reported significant improvements in ESS scores following CPAP therapy (Table 3
). Analysis of the HADS data revealed that up to 50% of patients and 52% of partners manifested symptoms of anxiety, and 44% of patients and 18% of partners had symptoms of depression on the initial questionnaire. After CPAP therapy, both anxiety and depression scores improved significantly (p = 0.001 and p = 0.02, respectively) in OSAS patients; in partners, anxiety levels improved significantly (p = 0.02). In the SF-36, patients with OSAS and their partners had a significantly impaired quality of life compared to age- and sex-matched normative Irish values (Tables 4
, 5
), 13
which improved dramatically in patients after CPAP therapy. In partners, significant improvements in the domains of role limitation due to physical problems (p = 0.02), role limitation due to emotional problems (p = 0.03), social functioning (p = 0.02), mental health (p = 0.03), and energy and vitality (p = 0.02) were reported.
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Table 4.. Comparison of SF-36 Scores Before and After CPAP Therapy in Patients (n = 45), and Irish Normative Data*
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Table 5.. Comparison of SF-36 Scores Before and After CPAP Therapy in Partners (n = 45) and Irish Normative Data*
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In OSAS patients, there was a significant correlation between hours of CPAP use and improvement in energy/vitality in OSAS patients (r = 0.374, p = 0.02), and a further significant relationship between initial ESS score in patients and HADS score (anxiety, r = 0.3, p = 0.04; depression, r = 0.4, p = 0.006), and various domains of the SF-36 (role limitation due to physical problems, r = 0.4, p = 0.004; energy/vitality, r = 0.5, p < 0.001; and general health perception, r = 0.3, p = 0.04). In partners of OSAS patients, the only significant correlations were between CPAP pressure and depression (as measured by HADS) [r = 0.3, p = 0.04], and CPAP pressure and general health perception (as measured by SF-36) [r = 0.3, p = 0.02]. There were no significant differences in baseline data of either patients or partners between those who showed major improvements vs those who had only minor improvements in quality of life as measured by HADS and SF-36.
The 10 couples who did not share a bed were no different than those who did share in terms of age, BMI, AHI, or pretreatment ESS score or quality-of-life indexes, although HADS and SF-36 scores tended to be worse at baseline in those partners who did not share a bed (Table 6
). At follow-up, ESS scores improved more with CPAP therapy in the partners of those patients who did share a bed (Table 3)
compared to those partners who did not share a bed (Table 6)
. However, both groups showed broadly similar improvements in quality-of-life measures after CPAP (Tables 5
, 6)
. The lack of statistically significant changes in several HADS and SF-36 measures in non-bed sharing partners is likely to be largely a reflection of inadequate sample size but unlikely to be so for ESS scores, although the small numbers involved make it difficult to be confident in this regard.
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Table 6.. Comparison of ESS Scores and HADS and SF-36 in Partners Not Sharing a Room, Before and After CPAP Therapy (n = 10)*
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Discussion
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The present findings indicate markedly impaired self-reported health status among partners of patients with OSAS when compared to matched normal Irish adults. These findings are similar to those previously reported in other studies,6
and support significant adverse effects of OSAS on partners. Our findings also demonstrate significant benefits in health status to partners from CPAP therapy to OSAS patients and support our previous retrospective findings in this regard.7
Our data suggest that the potential disadvantages of CPAP therapy are outweighed by the positive effects of successful treatment of OSAS related to the relief of snoring, apneas, and restless sleep.
Partners may have a diminished quality of life due to sleep fragmentation caused by sharing a bed with a patient who snores loudly and has a restless sleep pattern. Furthermore, partners may have insomnia from the worry caused by witnessing recurring apneas. Daytime symptoms in a sleep-deprived person include decreased mood, poor memory, and irritability, which may develop into tension between patient and partner and lead to a deterioration in their relationship. Cartwright and Knight16
compared social adjustment and marital satisfaction in divorced and married partners of OSAS patients and found that married partners were significantly more depressed and socially isolated than the divorced group. In another study17
examining sleep/wake patterns of 55 couples, those who had mismatched sleep/wake patterns showed lower marital adjustment than matched couples. In a Swedish study of 1,032 women,18
those living with heavy snorers were more affected by insomnia, morning headache, daytime sleepiness, and fatigue.
McArdle and coworkers,6
in a prospective, controlled study of 22 couples, also found that partners of patients with OSAS prior to CPAP therapy had impairments in both sleep quality and quality of life using validated questionnaires such as the Pittsburgh sleep quality inventory and the SF-36. However, they did not find any significant improvement in either Pittsburgh sleep quality inventory scores or the SF-36 in these partners after 1 month of CPAP therapy, although subjective improvements in partners’ sleep quality were noted. This study included a smaller number of patients and not all couples shared a bed on a regular basis, which might partly account for the different findings, but importantly was placebo controlled in design. In another prospective study, Armstrong and co-workers19
found a significant improvement in quality of life in both patients and partners after successful surgery for snoring. Our findings are also supported by the study of Beninati and coworkers,20
who showed improvement in quality of sleep of bed partners after initiation of CPAP therapy in a split-night study.
The comparison of outcomes between partners who did or did not share a bed with their respective OSAS patients provided some interesting findings. Partners who did not share a bed tended to have a poorer quality of life as measured by HADS and SF-36 compared to those who shared, but improvements in these measures following CPAP therapy were broadly similar in both groups. However, there was no difference in ESS scores before and after CPAP in partners who did not share a bed, whereas those who shared reported significant improvements with CPAP. These findings suggest a different response in terms of sleepiness and quality-of-life measures in the two groups. One could speculate that there may be a greater improvement in sleep quality among bed partners following CPAP therapy, reflecting less sleep disturbance from the CPAP device than from the untreated OSAS, whereas improvement in quality-of-life measures may be independent of whether or not the bed is shared and thus may be more a reflection of the indirect impact on the partner of the patient’s improvement in daytime alertness and quality of life. However, these findings are based on only 10 couples who did not share a bed and require confirmation in a larger patient population.
We recognize a number of limitations in our study design. The study was not placebo controlled, and thus is open to the potential influence of a placebo effect. However, since the partners themselves were not receiving any intervention in the present study, one might expect the placebo effect to be less pronounced. Furthermore, the marked impairment in quality of life of bed partners prior to therapy reported in our study and other studies should not have been influenced by the lack of a control group, and we believe it unlikely that such marked improvements in self-reported health status could be attributed entirely to placebo. Finally, the trend toward different outcomes comparing partners who did and did not share a bed suggests a real impact of CPAP on those who did share a bed, at least in terms of benefits to daytime sleepiness. Nonetheless, in light of the different findings of McArdle and coauthors,6
we acknowledge that part of the improvements observed among our partners following CPAP therapy may have reflected a placebo effect.
Our conclusions are based on the results of a self-completed questionnaire and thus are dependant on subjective responses, which could be influenced by the desire to give a favorable response to the investigators. Indeed, Bardwell et al21
compared the Marlowe-Crowne social desirability scale (used as a statistical control for response bias) with the SF-36 in 44 OSAS patients and found a significant relationship between the two. In an effort to minimize such potential bias, we performed an intent-to-treat analysis, and arbitrarily regarded those who failed to return the follow-up questionnaire as nonresponders. Since we did not have follow-up questionnaires on these six couples, we duplicated their pretreatment questionnaires as follow-up.
In conclusion, our data add to the growing body of evidence that bed partners of patients with OSAS have impaired quality of life and self-reported health status and, notwithstanding the study design limitations, that CPAP therapy ameliorates these abnormalities. These findings can be used to reinforce the potential benefits of CPAP therapy to both patients and their partners. As partners often initiate the referral for assessment, the physician and partner together could reinforce the importance of regular CPAP usage to the patient and potentially improve CPAP compliance,22
which has been reported in many studies to be in the region of 70%.23
24
25
26
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Footnotes
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Abbreviations: AHI = apnea-hypopnea index; BMI = body mass index; CPAP = continuous positive airway pressure; ESS = Epworth sleepiness scale; HADS = hospital anxiety depression scale; IQR = interquartile range; OSAS = obstructive sleep apnea syndrome; SF-36 = Short Form-36
Received for publication January 16, 2003.
Accepted for publication July 10, 2003.
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Abstract
Introduction
