The prevalence of sleep related disorders in Sivas, Turkey

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1 The prevalence of sleep related disorders in Sivas, Turkey Levent ÖZDEMİR 1, İbrahim AKKURT 2, Haldun SÜMER 1, Selma ÇETİNKAYA 1, Uğur GÖNLÜGÜR 2, Sefa Levent ÖZŞAHİN 2, Naim NUR 1, Ömer DOĞAN 2 1 Cumhuriyet Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, 2 Cumhuriyet Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı, Sivas. ÖZET Sivas ta uyku ile ilişkili bozuklukların sıklığı Türkiye de erişkinlerde uyku ile ilişkili bozuklukların sıklığı bilinmemektedir. Çalışmamızın ana amacı Sivas ta uyku ile ilişkili bozuklukların sıklığını ölçmekti. Çalışma, Türkiye de İç Anadolu nun bir ili olan Sivas ta yaşayan yaş arası erişkinlerde, 2701 (%50.6) i kadın 2638 (%49.4) i erkek toplam 5339 kişide uygulanmıştır. Uykusuzluk, horlama hastalığı, obstrüktif uyku apnesi, gündüz uykuya meyil sıklığı sırasıyla %40.3, %37.0, %6.4, %24.0 idi. Narkolepsi ve nokturnal myoklonus sıklığı sırasıyla %30.6, %40.1 idi. Altmış yaş üzeri grupla diğer yaş grupları arasında istatistiksel olarak anlamlı farklılık tespit edildi. Uyku ile ilgili bozukluk sıklığı açısından hem sigara içenler ve içmeyenler hem de erkek ve kadınlar arasında farklılık bulmadık (p> 0.05). Bununla beraber, hipertansiflerde uyku apnesi sıklığı hipertansif olmayanlara göre dokuz kat, şişmanlarda da 12 kat fazla idi. Çalışmamız ülkemizde uykuda solunum bozuklukları sıklığının diğer ülkeler kadar, belki de daha yaygın olduğunu göstermektedir. Anahtar Kelimeler: Sıklık, uyku bozukluğu, Türkiye. SUMMARY The prevalence of sleep related disorders in Sivas, Turkey Ozdemir L, Akkurt I, Sumer H, Cetinkaya S, Gonlugur U, Ozsahin SL, Nur N, Dogan O Department of Public Health, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey. The prevalence of sleep-related disorders (SRD) in adults in Turkey is unknown. The main objective of our study was to assess the prevalence of SRD in Sivas, Turkey. Adults living in Sivas, a city of Turkey from the central region of Anatolia at years of age, in both genders, of the 5339 persons, who attended the survey 2638 (49.4%) were male and 2701 (50.6%) were female. The prevalence of insomnia, habitual snoring, obstructive sleep apnea (OSA) and day time hyper somnolence was 40.3%, 37.0%, 6.4%, 24.0% respectively. The prevalence rates of narcolepsy and nocturnal myoclonus was 30.6%, 40.1% respectively. There was a statistical significance between the persons of above 60 years old and another age groups (p< 0.05). But we did not find any significant difference between smokers and non-smokers, also between males Yazışma Adresi (Address for Correspondence): Dr. Levent ÖZDEMİR, Cumhuriyet Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, SİVAS - TURKEY 19 Tüberküloz ve Toraks Dergisi 2005; 53(1): 19-26

2 The prevalence of sleep related disorders in Sivas, Turkey and females about SRD prevalence (p> 0.05). However, sleep apnea prevalence was about 9 times higher in the persons suffering from hypertension than without hypertension. Also sleep apnea prevalence was 12 times higher in the persons suffering from overweight. This study has shown that sleep-disordered breathing (SDB) prevalence in Turkey is as high as in other countries and may be more common. Key Words: Prevalence, sleep disorder, Turkey. Sleep related disorder (SRD) is an extremely common medical disorder that is associated with considerable morbidity. Sleep apnea has been recognized as an important clinical condition only for the past 30 years (1). Various studies have reported community prevalence of habitual snoring in adults to be about %. About 30-50% of adult habitual snorers are estimated to have sleep apnea/hypopnoea, which is estimated to occur in % of the general population (2-4). Habitual snoring has been shown to be independently associated with the development of stroke, hypertension, and myocardial infarction in the general population (5-7). Under diagnosed SRD represents a major public health burden (8). Excessive sleepiness has been increasingly recognized as an important public health problem, estimated to affect at least 12 to 20% of the general adult population and contributing to both motor-vehicle and work-related accidents, impaired social functioning, and reduced quality of life (9,10). Although cases of SRD have been documented in most of countries, in our knowledge, its prevalence is unknown in Turkey. So, in this study, we attempted to determine the prevalence of symptoms related to SRD in the adult population in Sivas, Turkey by a questionnaire survey. MATERIALS and METHODS The study population included the inhabitants of Sivas, at or above 20 years of age, selected randomly and gave consent to the study. The study region was Sivas, far from Ankara nearly 450 kilometres, in the north-eastern region of central Anatolia, with a population of The population of 20 years or above of age was (1997 national census, and yearly health statistic findings). When expected prevalence of SRD was thought to be 10.0%, statistically expected population to reach was calculated from known formulation as 5846 persons who consist of a simple random sample of clusters of individuals. The study region was Sivas, has a dry and cold climate, and the air pollution level is much higher especially at winter like other Turkish cities. This was a cross-sectional study including a questionnaire survey. Turkish-language version of the modified Sleep and Health Questionnaire is a modified version of the Specialised Centres of Research Sleep Questionnaire, which has been shown previously to be a valid means of characterising symptom distribution in population surveys of sleep apnea. The questionnaire contains 47 questions grouped into five factors (demographic characteristics/smoking habits, insomnia, sleep apnea, narcolepsy, and nocturnal myoclonus) that have been shown to be useful in predicting the occurrence of SRD (11-14). Questionnaire forms were given to the subjects by face to face interviewing method. From totally 5846 forms, 5339 (91.3%) were answered while the others were rejected or not found. The answers to the related SRD questions utilized either yes or no. These questions are shown in the Results tables. Findings of the study are presented as the mean ± SD for the numbers and the prevalence rate for the frequencies. In the statistical comparisons t-test, Fisher exact Chi-Square test and Mantel-Haenszel for estimated common Odds Ratio were used. Statistical significance was assumed for a value of p< RESULTS From totally 5846 persons, 5339 (91.3%) were included into the study. Of the 5339 adults, who attended the survey, 2638 (49.4%) were male and 2701 (50.6%) were female. Table 1 shows the age, gender, and smoking behaviour of the study population. The age range of the survey population was 20 to 107 years with the mean Tüberküloz ve Toraks Dergisi 2005; 53(1):

3 Özdemir L, Akkurt İ, Sümer H, Çetinkaya S, Gönlügür U, Özşahin SL, Nur N, Doğan Ö. Table 1. Gender, age and smoking behaviour of the study population. Men Women Total n (%) 2638 (49.4) 2701 (50.6) 5339 (100.0) Mean age (SD) 40.0 (12.0)* 36.9 (13.1)* 38.4 (12.6) Ever smoked n (%) 1297 (49.2)* 374 (13.8)* 1671 (31.3) * p< age of 38.4 years (SD= 12.6 years). Almost half of the study population were at or below 40 years of age. There were 1297 (49.2%) men and 374 (13.8%) women who admitted that they have smoked. The prevalence of ever smoking among the men were statistically higher than women (p< 0.001). The questions and answers of the cases related to insomnia are shown on Table 2. The prevalence of insomnia was 40.3% (2152). The prevalence rates of habitual snoring, obstructive sleep apnea (OSA) and day time hyper somnolence were 37.0% (1977), 6.4% (342) and 24.0% (1280) respectively. When we take into account at least 3 yes answers to these questions related to sleep apnea, the prevalence was found 43.7% (2331) (Table 3). The prevalence of narcolepsy was 30.6% (1633) (Table 4). The questions and answers of the cases related to nocturnal myoclonus have been shown on Table 5. The prevalence rate of nocturnal myoclonus was 40.1% (2139). Table 6 shows the prevalence of SRD according to age groups. There was a statistical significance between the persons of above 60 years old and another age groups (p< 0.05). But we did not find any significant difference between smokers and non-smokers, also between males and females about SRD prevalence rate (p> 0.05). However, sleep apnea prevalence was about 9 times higher in the persons suffering from hypertension than the subjects without hypertension. Also sleep apnea prevalence was 12 times higher in the persons suffering from overweight (Table 7). DISCUSSION Obstructive sleep apnea syndrome (OSAS) is the most common organic disorder of excessive daytime somnolence. In cross-sectional studies the minimum prevalence of OSAS among adult men is about 1%. Prevalence is the highest among men aged years. The highest figures for this age group indicate that their prevalence of clinically significant OSAS may be 8.5% or higher. The most significant risk factor for OSAS is obesity, especially upper body obesity. Table 2. The questions and answers of the cases related to insomnia (n= 5339). Yes Questions n % Do you have difficulty to sleep? Do you feel like you can not sleep due to your constant thoughts? Are you afraid that something bad will happen when you are sleeping? Do you occupy yourself with worriment for everything? Do you wake up feeling that you did not get enough sleep? Is it taking you at least half an hour to fall asleep? Are you upset and unhappy? Do you have problem of waking in the night and not being able to sleep again? INSOMNIA (at least 3 yes answers to these questions) Tüberküloz ve Toraks Dergisi 2005; 53(1): 19-26

4 The prevalence of sleep related disorders in Sivas, Turkey Table 3. The questions and answers of the cases related to sleep apnea (n= 5339). Yes Questions n % Did anybody tell you that you are snoring whenever you sleep? Did anybody tell you that you stop breathing when you sleep? Do you have high blood pressure? Did anybody tell you that there are changes in your attitude? Did you put on too much weight lately? Do you sweat a lot during night? Does your heart beat irregularly during night? Do you wake up with headache in the morning? Do you have difficult sleeping when you have flu? Do you wake up in the night with shortness of breath? Are you overweight? Do you think there is a decrease in your sexual performance? Do you feel sleepy during the day although you get enough sleep during the night? SLEEP APNEA (at least 3 yes answers to these questions) Table 4. Narcolepsy related questions and answers (n= 5339). Yes Questions n % Are you having difficulty to concentrate? Do you feel numb when you are nervous? Do you feel sleepy when you drive? Do you feel dazed sometimes? Do you see any image that seems alive when you were falling sleep or waking up? Do you feel sleepy when you work? Do you hear or see anything unreal when you fall asleep? Do you feel you need to finish all day work in an hour and get frustrated? Do you fall asleep when you laugh or cry? Do you think that you are unsuccessful in your work since you are sleepy most of the time? Do you see any nightmares right after you fall asleep? Do you feel sleepy all day long? Do you feel it is difficult to stay awake and you can sleep under any circumstance? Do you feel your actions/motions are blocked when you fall asleep or wake up? NARCOLEPSY (at least 3 yes answers to these questions) Tüberküloz ve Toraks Dergisi 2005; 53(1):

5 Özdemir L, Akkurt İ, Sümer H, Çetinkaya S, Gönlügür U, Özşahin SL, Nur N, Doğan Ö. Table 5. The questions and answers of cases related to nocturnal myoclonus (n= 5339). Yes Questions n % Do you feel that your leg muscles are strecthed even when you are rested? Do you feel shivering in your body? Have you ever been told that you are kicking while you are sleeping? Do you have any pain or feel numb in your legs? Do you suffer from leg pain during night? Do you need to move your legs while sleeping at night? Do you wake up with muscle pain? Do you feel sleepy during the day even when you get enough sleep? NOCTURNAL MYOCLONUS (at least 2 yes answers to these questions) Table 6. Prevalence of SRD according to age groups. Age Sleep Nocturnal groups Insomnia apnea Narcolepsy myoclonus Total (years) n % n % n % n % n % * * * * Total p< Table 7. The risk factors related to sleep-disordered breathing (SDB). With healthy Without healthy p: Overweight Not overweight p: persons persons OR*: persons persons OR: (n= 733) (n= 4606) (95% CI)** (n= 683) (n= 4656) (95% CI) Insomnia n (%) 464 (63.0) 1688 (36.6) (55.8) 1771 (38.0) ( ) ( ) Sleep apnea n (%) 622 (84.6) 1711 (37.1) (87.7) 1732 (37.2) ( ) ( ) Narcolepsy n (%) 363 (49.5) 1270 (27.6) (46.0) 1319 (28.3) ( ) ( ) Nocturnal myoclonus n (%) 448 (61.1) 1691 (36.7) (58.9) 1737 (37.3) ( ) ( ) * OR: Odds ratio. ** 95% CI: Confidence Interval 95%. 23 Tüberküloz ve Toraks Dergisi 2005; 53(1): 19-26

6 The prevalence of sleep related disorders in Sivas, Turkey Other risk factors for snoring, and for OSAS, are male gender, age between 40 and 65 years, cigarette smoking, use of alcohol, and poor physical fitness (15). Ulfberg et al. reported that sleep related complaints were more frequent among the restless leg syndrome (RLS) sufferers (16). Although questionnaires have been developed to assess symptoms of obstructive sleep apnea (OSA), their overall reliability and utility have not been established. Kump et al. had evaluated the ability of a questionnaire to identify increased apnea activity in 465 participants in an epidemiological study of OSA and shown that questionnaire data provide a valid means of characterizing symptom distributions in population surveys of OSA (11). This study confirms that SRD may be very prevalent in the general population. The present results are strengthened by the very high response rate of 91.3%. Our findings of habitual snoring in 37.0% of the population, breathing pause in 6.4%, and day time hyper somnolence in 24.0% are nearly consistent with those found by others and indicate that symptoms of SRD are common in the general population (8,17-19). The sleep history is essential to recognize clinically important sleep disorders (20). Recent epidemiological observations suggest that approximately 90.0% of persons with clinically significant OSA have not been recognized (21). If potentially treatable sleep problems are to be recognized and managed, then the barriers to optimal health-care provider behaviours must be defined and addressed. Further prospective study may require not only a large cohort but also a refined prompt that more emphatically promotes a response by the caregiver. The low frequency of action may reflect physicians suboptimal knowledge and attitudes about sleep disorders and suggest an important educational need (20). The American Sleep Disorders Association Taskforce 2000 Survey has confirmed that physicians receive, on average, only 2.1 h of education in the area of sleep disorders after 4 years of medical education (22). In our knowledge, in Turkey, physicians receive, on average, only one hour of education in the area of sleep disorders after 6 years of medical education. Namen and colleagues believe that chest clinicians active in the evaluation and management of patients with SRD must have a major role in this educational effort. We have been set up polysomniagraphy (PSG) unit in our chest clinic, but firstly we established this questionnaire survey to detect general population in our region by symptoms, demographic characteristics, and risk factors. Hui et al. analyzed the potential factors that may predict snoring and SRD. They reported that male gender is significantly related with snoring (12). Duran et al. reported that the prevalence of habitual snoring is 35.0%, and they concluded that there is a link between hypertension and obstructive sleep apnea-hypopnoea (OSAH) in the general population (8). Carmelli et al. reported that, the prevalence of self-reported snoring is 26.0%, excessive daytime sleepiness (EDS) is 18.0%. By using structural equation modelling, they estimated that genetic factors accounted for 64.0% of the variance in obesity, 40.0% of the variance in daytime sleepiness, and 23.0% of the variability in self-reports of snoring. And they concluded that self-reported symptoms of snoring and daytime sleepiness in older men have a genetic basis (23). Ng et al. reported that marked ethnic differences in snoring and sleep breathing-related disorders were observed in Chinese, Malays and Indians in Singapore, which were only partly explained by known factors of sex, age and body habitus (24). Habitual snoring was reported as 23.0% by Ip et al. and was associated with EDS; hypertension, witnessed abnormal breathing pattern, body mass index (BMI), and leg movements during sleep (25). In our study, the prevalence of habitual snoring was 37.0% (1977), and OSA was 6.4% (342), day time hyper somnolence was 24.0% (1280). When we take into account at least 3 yes answers to these questions related to sleep apnea, the prevalence was found as 43.7% (2331) (Table 3). The prevalence of narcolepsy, and nocturnal myoclonus was 30.6%, 40.1% respectively (Table 4, 5). Although OSA is associated with chronic hypertension, not all subjects with SRD are hypertensive (26-28). A form of SRD is upper airway resistance syndrome (UARS). Guilleminault et al. concluded that approximately Tüberküloz ve Toraks Dergisi 2005; 53(1):

7 Özdemir L, Akkurt İ, Sümer H, Çetinkaya S, Gönlügür U, Özşahin SL, Nur N, Doğan Ö. one fifth of subjects with UARS have low blood pressure and complain of orthostatic intolerance (29). In our study, sleep apnea prevalence was about 9 times higher in the persons suffering from hypertension than people without hypertension. Klink et al. found that among subjects with no respiratory symptoms, 28.0% reported insomnia (difficulty initiating or maintaining sleep) and 9.0% reported daytime sleepiness. Among subjects with respiratory symptoms the rates were 52.8% and 22.8%, respectively (30). In our questionnaire survey, the prevalence of insomnia was 40.3% (2152). Schmitt et al. were demonstrated the variety of sleep disorders occurring in a working population in Switzerland using a questionnaire. They found that the prevalence rates of OSA, RLS, disorders of initiating and maintaining sleep, and narcolepsy were 6.0%, 4.0%, 19.0%, and 0.5% respectively (31). Köktürk et al have reported that the frequency of OSA was determined in 15 (%27.3) of 55 patients with habitual snoring (32). Ganguli et al. reported the prevalence and persistence of sleep complaints in a rural older community sample. They found that the prevalence of snoring was 40.0%, and snoring was significantly more common among men (33). Ulfberg et al. had reported that the specificity of the questions about snoring as 83.0% and the sensitivity as 42.0%. The risk ratios for reporting EDS at work were 4- fold for snorers in the general population, 20- fold for snoring patients, and 40-fold for patients with OSA as compared with no snoring men in the general population (34). Van Kralingen et al. investigated sleep-related complaints and frequency of SRD in a group of obese persons as part of a preoperative workup for weight reduction surgery and found that the prevalence of SRD in obese patients was 35.0% (35). In our study, sleep apnea prevalence was 12 times higher in the persons suffering from overweight than others (Table 7). Tachibana et al. examined the prevalence of insomnia among Japanese male industrial workers and found that insomnia within the month preceding the survey was present in 27.7% of the workers (36). Recently, Krakow et al. assessed the prevalence of insomnia symptoms in patients with objectively diagnosed as sleep-disordered breathing (SDB) and concluded that problematic insomnia symptoms were reported by 50.0% of a representative sample of patients with objectively diagnosed as SRD (37). In our study, the prevalence of insomnia was found as 40.3%. This study has shown that SDB prevalence in Turkey is as high as in other countries and may be more common. In fact, PSG is the gold-standard test for the diagnosis of SRD. However, our results have shown that in large populations questionnaires can also give some knowledge about SRD. By questionnaire assessment, SRD prevalence is high among adult people in Sivas, Turkey. We believe that further studies are required to determine the morbidity, mortality, and economic loss associated with SRD in general population, especially in risk groups. REFERENCES 1. Schwab RJ, Goldberg AN, Pack AI. Sleep apnea syndromes. In: Fishman AP (ed). Fishman s Pulmonary Diseases and Disorders. New York: International Edition, McGraw-Hill, 1998: Fitzpatrick MF, Martin K, Fossey E, et al. Snoring, asthma, and sleep disturbance in Britain: a community-based survey. Eur Respir J 1993; 6: Gislason T, Almqvist M, Ericksson G, et al. Prevalence of sleep apnea syndrome in Swedish men: an epidemiological study. J Clin Epidemiol 1988; 1: Olson LG, King MT, Hensley MJ, et al. A community study of snoring and sleep-disordered breathing. Prevalence. Am J Respir Crit Care Med 1995; 152: Partinen M, Palomak H. Snoring and cerebral infarction. Lancet 1985; 2: Koskenvuo M, Kaprio J, Partinen M, et al. Snoring as a risk factor for hypertension and angina pectoris. Lancet 1985; 1: Koskenvuo M, Kaprio J, Telakivi T, et al. Snoring as a risk factor for ischemic heart disease and stroke. BMJ 1987; 294: 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 Med 2001; 163: Gottlieb DJ, Yao Q, Redline S, et al. Does snoring predict sleepness independently of apnea and hypopnea frequency? Am J Respir Crit Care Med 2000; 162: Masa JF, Rubio M, Findley LJ. Habitual sleepy drivers have a high frequency of automobile crashes associated 25 Tüberküloz ve Toraks Dergisi 2005; 53(1): 19-26

8 The prevalence of sleep related disorders in Sivas, Turkey with respiratory disorders during sleep. Am J Respir Crit Care Med 2000; 162: Kump K, Whalen C, Tishler PV, et al. Assessment of the validity and utility of a sleep-symptom questionnaire. Am J Respir Crit Care Med 1994; 150: Hui DSC, Chan JKW, Ho ASS, et al. Prevalence of snoring and sleep disordered breathing in a student population. Chest 1999; 116: Barış Yİ. Solunum Hastalıkları Temel Yaklaşım. Üçüncü Baskı. Ankara: Atlas Kitapçılık Tic. Ltd. Şti., Akkurt İ, Seyfikli Z, Doğan Ö. The relation between sleep related disorders (SRD) and traffic accidents among the drivers in Sivas, Turkey. Eur Respir J 2001; 18 (Suppl 33): Partinen M, Telakivi T. Epidemiology of obstructive sleep apnea syndrome. Sleep 1992; 15 (6 Suppl): Ulfberg J, Nystrom B, Carter N, Edling C. Prevalence of restless legs syndrome among men aged 18 to 64 years: an association with somatic disease and neuropsychiatric symptoms. Mov Disord 2001; 16: Olson LG, King MT, Hensley MJ, et al. A community study of snoring and sleep-disordered breathing. Symptoms. Am J Respir Crit Care Med 1995; 152: Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328: Ohayon MM, Guilleminault C, Priest RG, et al. Snoring and breathing pauses during sleep: telephone interview survey of a United Kingdom population sample. BMJ 1997; 314: Namen AM, Wymer A, Case D, et al. Performance of sleep histories in an ambulatory medicine clinic. Chest 1999; 116: Young T, Evans L, Finn L, et al. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20: Rosen R, Mahowald M, Chesson A, et al. The taskforce 2000 survey on medical education in sleep and sleep disorders. Sleep 1998; 21: Carmelli D, Bliwise DL, Swan GE, et al. Genetic factors in self-reported snoring and excessive daytime sleepiness. Am J Respir Crit Care Med 2001; 164: Ng TP, Seow A, Tan WC. Prevalence of snoring and sleep breathing-related disorders in Chinese, Malay and Indian adults in Singapore. Eur Respir J 1998; 12: Ip MSM, Lam B, Lauder IJ, et al. A community study of sleep-disordered breathing in middle-aged Chinese Men in Hong Kong. Chest 2001; 119: Duchna HW, Guilleminault C, Stoohs RA, et al. Vascular reactivity in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2000; 161: Nieto FJ, Young TB, Lind BK, et al. Association of sleepdisordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000; 283: Lavie P, Herer P, Hoffstein V. Obstructive sleep apnoea syndrome as a risk factor for hypertension: population study. BMJ 2000; 320: Guilleminault C, Faul JL, Stoohs R. Sleep-disordered breathing and hypotension. Am J Respir Crit Care Med 2001; 164: Klink ME, Dodge R, Quan SF. The relation of sleep complaints to respiratory symptoms in a general population. Chest 1994; 105: Schmitt BE, Gugger M, Augustiny K, et al. Prevalence of sleep disorders in an employed Swiss population: results of a questionnaire survey. Schweiz Med Wachenchr 2000; 130: (English abstract). 32. Köktürk O, Tatlıcıoğlu T, Kemaloğlu Y, et al. Habituel horlaması olan olgularda obstrüktif sleep apne sendromu prevalansı. Tüberküloz ve Toraks 1997; 45: Ganguli M, Reynolds CF, Gilby JE. Prevalence and persistence of sleep complaints in a rural older community sample: the MOVIES project. J Am Geriatr Soc 1996; 44: Ulfberg J, Carter N, Talbück M, Edling C. Excessive daytime sleepiness at work and subjective work performance in the general population and among heavy snorers and patients with obstructive sleep apnea. Chest 1996; 110: Van Kralingen KW, de Kanter W, de Groot GH, et al. Assessment of sleep complaints and sleep-disordered breathing in a consecutive series of obese patients. Respiration 1999; 66: Tachibana H, Izumi T, Honda S, et al. The prevalence and pattern of insomnia in Japanese industrial workers: relatinoship between psychosocial stress and type of insomnia. Psychiatry Clin Neurosci 1998; 52: Krakow B, Melendrez D, Ferreira E, Clark J. Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest 2001; 120: Tüberküloz ve Toraks Dergisi 2005; 53(1):

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