Arq Bras Endocrinol Metabol. 2013 Aug;57(6):425-30.

Excessive daytime sleepiness in type 2 diabetes.

Medeiros C, Bruin V, Férrer D, Paiva T, Montenegro Júnior R, Forti A, Bruin P.

Faculdade de Medicina, Universidade Federal do Ceara, Fortaleza, Brazil

 

Abstract

Daytime sleepiness is a major public health issue and has been recognized as an independent factor for all cause mortality. Diabetic patients are more likely to be sleepy during the daytime than non-diabetics. A greater risk for traffic accidents due to somnolence has been shown in diabetic patients. Also, sleepiness is associated with a general decrease in motivation to engage in activities that are important in the management of diabetes. Therefore, clarifying the mechanisms involved in sleep disorders and daytime somnolence in type 2 diabetes may be important to improve therapy in these patients. This study evaluated excessive daytime sleepiness (EDS) in type 2 diabetes and its associations with depressive symptoms, other sleep complaints and clinical/laboratory variables. Patients (N=110) were evaluated regarding EDS (Epworth Sleepiness Scale>10), sleep quality (Pittsburgh Sleep Quality Index), depressive symptoms (Beck Depression Inventory), Restless Legs Syndrome (RLS), risk of obstructive sleep apnea (OSA) (Berlin questionnaire) and comorbidity severity (Charlson Comorbidity Index). Cases were compared with individuals with arterial hypertension and without diabetes. Diabetic patients had more EDS, depressive symptoms and higher comorbidity severity than hypertensive patients (p<0.005). In diabetic patients, poor quality sleep (53.3%), high risk of OSA (40.9%) and RLS (14.5%) were found; EDS (55.5%) was associated with depressive symptoms present in 44.5% (OR=1.08; 95% CI: 1.01-1.15), and remained so after controlling for age, gender, body mass index and glycated hemoglobin (OR=2.27; 95% CI 1.03-5.03). Sleep abnormalities are frequent and excessive daytime sleepiness affects more than half of patients with type-2 diabetes. In diabetic patients, daytime somnolence is independently associated with depressive symptoms. We suggest that in diabetic patients should be more thoroughly investigated and possibly treated for depressive symptoms: adequate antidepressant therapy should be tested for the effects on EDS.

KEY WORDS: Diabetes; sleep; depression; apnea; comorbidity

 

Supplements:

Daytime sleepiness is a major public health issue and has been recognized as an independent factor for all cause mortality (1). Diabetic patients are more likely to be sleepy during the daytime than non-diabetics. A greater risk for traffic accidents due to somnolence has been shown in diabetic patients (2). Also, sleepiness is associated with a general decrease in motivation to engage in activities that are important in the management of diabetes. Therefore, clarifying the mechanisms involved in sleep disorders and daytime somnolence in type 2 diabetes may be important to improve therapy in these patients.

We evaluated the frequency of excessive daytime sleepiness in type 2 diabetes and its associations with depressive symptoms, other sleep complaints and clinical/laboratory variables.

Daytime somnolence was assessed by the Epworth Sleepiness Scale (ESS). Epworth Sleepiness Scale score>10 indicates excessive daytime sleepiness. Subjective sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI). Individuals with PSQI score>six were considered poor sleepers. Depressive symptoms were evaluated by the Beck Depression Inventory (BDI>10). Frequent associated comorbidities such as hypertension, high risk of OSA and restless legs syndrome that might influence excessive daytime sleepiness were analyzed. Risk of having OSA was assessed by the Berlin questionnaire. Comorbidities were assessed with the Charlson Comorbidity Index (CCI).

Type 2 diabetes patients (N=110), mostly female (65.8%; mean age= 57.6±11.0) were compared to individuals with arterial hypertension (N=36; 58.3% female; mean age=57.6±9.7). Patients with diabetes showed greater comorbidity severity (CCI), more depressive symptoms (BDI) and more severe excessive daytime sleepiness (ESS) (p<0.005). Cases with arterial hypertension had worse sleep quality (PSQI, p<0.005).

Veralice Meireles Sales de Bruin-1

Abbreviations: ESS, Epworth Sleepiness Scale; M/F, Male/Female; BMI, Body Mass Index; BDI Beck Depression Inventory; PSQI Pittsburgh Sleep Quality Index; CCI Charlson Comorbidity Index; OSA Obstructive Sleep Apnea. a Fisher Exact Test, b Student’s Test, c Mann-Whitney Test

 

Excessive daytime sleepiness in diabetic patients (55.5%) was not related to gender, age, disease duration, BMI, waist-hip ratio and laboratory results. Diabetic patients with excessive daytime sleepiness showed significantly higher BDI scores than non diabetics (11.43±6.79 vs 8.43±6.0, p=0.01, respectively). An association between excessive daytime sleepiness and depressive symptoms was found (OR=1.08; 95% CI: 1.01-1.15) and remained significant after controlling for age, gender, BMI and glycated hemoglobin (OR= 2.27; 95% CI: 1.03-5.03).

Veralice Meireles Sales de Bruin-2
Model 1- In this unadjusted model, Beck Depression Inventory scores, Pittsburgh Sleep Quality Index scores and Charlson Comorbidity Index scores were entered as numerical variables and Restless Legs Syndrome, Hypertension and High risk of obstructive sleep apnea as dichotomized variables (present/absent). Hosmer-Lemeshow goodness-of-fit tests showed 9.65 and p =0.29 demonstrating a good fit of the models. Model 2- In this model data have been adjusted for age, gender, body mass index and glycated hemoglobin.

Poor sleep quality in diabetic patients (53.3%) and was not associated with daytime sleepiness. Restless leg syndrome (14.5%) and arterial hypertension (70.0%) were not associated with excessive daytime sleepiness. The risk of OSA (Berlin questionnaire, 40.9%) was not associated with excessive daytime sleepiness. Comorbidity severity (CCI) was not associated with excessive daytime sleepiness. The most common complications associated with diabetes were peripheral neuropathy (31.2%), retinopathy (17.8%), cataract (19.0%) and renal disease (5.4%). Depressive symptoms (BDI, 44.5%) were associated with poor sleep quality (PSQI, OR= 1.39; 95% CI: 1.21-1.59).

The important findings of this study are:

  • Excessive daytime sleepiness is frequent in type-2 diabetes, affecting more than half of patients
  • Excessive daytime sleepiness is independently associated with depressive symptoms

We suggest that diabetic patients with excessive daytime sleepiness should be more thoroughly investigated and possibly treated for depressive symptoms. Proper therapy might improve alertness and psychological well-being leading to better cooperation and disease control.

 

References

(1)          GOONERATNE NS, RICHARDS KC, JOFFE M, et al. Sleep disordered breathing with excessive daytime sleepiness is a risk factor for mortality in older adults. Sleep 2011; 34: 435-42.

(2)          HAYASHINO Y, YAMAZAKI S, NAKAYAMA T, SOKEJIMA S, FUKUHARA S. Relationship between diabetes mellitus and excessive sleepiness during driving. Exp Clin Endocrinol Diabetes 2008; 116: 1-5.

 

Contact

Dr. Veralice Meireles Sales de Bruin, MD, PhD

Associate Professor of Neurology

Faculdade de Medicina, Universidade Federal do Ceara

R. Cel Nunes de Melo 1315 – Rodolfo Teófilo – CEP 60.430-270

Fortaleza, Ceará, Brazil.

Email: veralice@superig.com.br

veralicebruin@gmail.com

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