1. Obstructive sleep apnoea and type 2 diabetes: Whose disease is it anyway? 14 December 2010

3. OSA What is it? Why is it important for diabetes? What have we been doing?

5. What are the symptoms Snoring Restless, unrefreshing sleep Waking with choking or gasping Morning headaches Nocturia Difficulty concentrating Impotence Reflux PLUS Difficult to control H/T Poor control of diabetes

6. Sleepiness or fatigue? Sleepiness Inability to remain fully awake when you should be Fatigue Subjective lack of physical or mental energy that interferes with activities CLOSE CALL

7. Who is at risk 25% of adult population at high risk increases with age Men>women OBESITY, particularly neck measurement Smokers (current have x3 incidence) Blocked nose (x2)

8. Why does it matter Severe untreated OSA increases all cause mortality by x 3 to x 6 Associated with systemic H/T CAD Arrhythmias Ischaemic stroke Heart failure RTA Pre-operative complications Diabetes and insulin resistance

9. Do Surrey Residents Really Snore?

10. Pilot study To give us a rough idea of prevalence of OSA in local population to help with forward planning Cedar Centre SD Dr Chris Hands Academic F2 Sleep Team Denise Daley Consultant Katherine Marshall physiotherapist

11. Case Study Mr R M Age 71 BMI 33 HBA1C 10.3 BP 132/61 Comorbidities Urinary retention TKR 2007 (Post op neuropathic pain) Dual chamber pacemaker Hypertension Renal stones Type 2 diabetes (1986) Renal stones/stents

12. Never smoker Min ETOH Snorer, Witnessed apnoeas Nocturesis Poor control diabetes No nasal trauma /symptoms

13. Drug history Allopurinol 400mg Humalog 50/55/60 Aspirin 5mg Metformin 500mg Effercitrate Insulin Gabapentin 300mg tds Amitryptyline 50mg nocte Simvastatin 40mg Valsartan 80mg Bisoprolol 2.5mg Nitrofurantoin 50mg Amlodipine 5mg Furosemide 40mg Cocodamol30/500

15. CPAP 31/05/2011 TKR 14/06/2011 Epworth came down (15 to 8) 6+hours CPAP per night

16. The kit

17. Cedar Pilot study Information and questionnaire given to patients on arrival at clinic No patient selection (T1/T2, fat/thin etc)

18. Cedar Pilot study Information and questionnaire given to patients on arrival at clinic No patient selection (T1/T2, fat/thin etc) Patients put completed questionnaires put in a box in the waiting area Scored later

20. SCORE positive if:  Scored 9 or more on the Epworth Scale  Those with observed pauses in breathing  Snorers with a BMI over 30

21. 65 questionnaires given out 62 Returned =95% 34 positive 55% *20 Epworth>9 *14 snorers BMI>30 *6 observed pauses 28 negative RESULTS *Not mutually exclusive

22. Summary 3 clinics 65 patients 54% screen positive 17 studied 4 mild OSA 5 severe OSA

23. What are the implications for our clinical practice?

24. What next Screen every one Screen no one POTENTIAL BENEFITS Improved glycaemic control Reduced risk of stroke Reduced risk of road accidents Improved quality of life Divorce stats??

25. What next?  Screen all pts with diabetes?  Screen all patients with type 2?  Screen all those with BMI >?  Opportunistic screening?  Nothing?

28. Summary Questionnaires62 For screening34 Declined Ax7 Did not make an appointment 10 Sleep studies17 Negative8 Mild, D/C with advice 3 Mild, lifestyle changes FU 6/12 1 CPAP trial DC1 On CPAP4 Hi Sue, Please find the picture attached. It is in a word file as it was in a presentation. Data from our clinics: Hope this makes sense. Let me know if not or if you have any queries. There were 8 negative studies and 9 positive of which 4 are on CPAP, one tried CPAP but didn't get on with it, one is having a repeat sleep study in 6 months as he attempts to lose weight and 3 others were mild and D/C with advice.

29. Sleep disordered breathing Sleep disordered breathing (adults) Apnoeas hypopnoeas OSA Central eg Cheynes Stokes Others! AI number of apnoeas per hour of sleep AHI total number of apnoeas and hypopnoeas per hour of sleep

30. Who was Epworth? Epworth near Melbourne

31. 34 screen positive 7 declined appointment 10 no response 17 studied 8 negative4 mild3 discharged 1 restudy in 6/12 5 severe 4 on CPAP RESULTS

32. Screening people with type 2 diabetes for OSA is more complex, however they should be screened particularly when they present with classical symptoms such as witnessed apnoeas, heavy snoring or daytime sleepiness.