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Isayeva Anna,
Government Institution "L. T. Malaya Therapy Institution of The National Academy of Medical Sciences of Ukraine" Head of the Department of Chronic Non-communicable
Disease Prevention, Ph D., Buriakovska Olena, Government Institution "L. T. Malaya Therapy Institution of The National Academy of Medical Sciences of Ukraine" Junior research Associate of the Department of Chronic Non-communicable Disease Prevention E-mail: alena.tbtch@gmail.com
SLEEP DISORDERS IN PATIENTS WITH HYPERTENSION AND DIABETES MELLITUS
Abstract. Epidemiological studies show a link between insomnia and risk of development of hypertension and diabetes mellites as well as with a prognosis in people suffering these diseases. The study included 43 patients. Mean age of study subjects was 57.2 ± 11 years. All patients received standard therapy: valsartan, metformin and atorvas-tatin. Sleep disorders were assessed using the International Sleep Disorder Classification, edition 3, developed by the American Academy of Sleep Medicine, 2014 and Epworth Sleepiness Scale. Statistical analysis was performed using SPSS software, version 17.0. Sleep disorders were observed in both study groups, however, patients with hypertonic disease and type 2 diabetes mellitus reported reliably more difficulties in falling asleep (10 (40%) vs 2 (11.1%), p = 0.038) and early rising (18 (72%) vs7 (38.9%), p = 0.032), and consequently, behavioral problems were predominant among daily symptoms: increased emotionality, irritability, frequent mood swings. According to Epworth Sleepiness Scale, sleepiness in patients with combined course of hypertonic disease and type 2 diabetes mellitus was 6.7 points, while in control group ofhealthy volunteers, the score was 4.1 points. In patients with hypertonic disease and type 2 diabetes mellitus, disorders were more frequent in falling asleep and early rising, while impairment of usual sleep-awake regimen and inability to maintain continuous sleep were observed with similar frequency in both groups.
Keywords: diabetes mellitus, hypertension, sleep disorders, insomnia, day sleepness.
Currently, hypertonic disease and type 2 diabetes mellitus are among the most common chronic non-infectious diseases and are of special interest among scientists and investigators in terms of determination of risk factors affecting their development, course and complications. Thus, within the last few years, epidemiologic studies demonstrated interrelation between insomnia, development of hypertonic disease, type 2 diabetes mellitus, life expectancy and body ageing in general. At the same time, these studies applied various methodic approaches to assessment of sleep disorders. Also, sleep disorder risk factors were not assessed. It should be noted that sleep disorders are quite common within general population and by no means always cause development of non-infectious diseases. Therefore, the purpose of this work was to study the relation between sleep changes and their day-time consequences with hypertonic diseases and type 2 diabetes mellitus.
Materials and methods. The study included 25 patients with combined course of hypertonic disease and type 2 dia-
betes mellitus. Type 2 diabetes mellitus was diagnosed based on the criteria by ADA/European Assotiation for the Study of Diabetes (EASD) Position Statement on Management of Hyperglycemia in Type 2 Diabetes - Update January 2015. Hypertonic disease was diagnosed in accordance with definition laid down in the Guideline of European Society of Cardiology ESC2013 Arterial Hypertension (Management of) ESC Clinical Practice Guidelines. All patients received standard therapy: valsartan, metformin and atorvastatin. Mean age of study subjects was 57.2 ± 11 years. Height, weight, waist circumference were measured in all patients enrolled into the study. Control group included 18 patients without hypertonic disease and type 2 diabetes mellitus. Body mass index (BMI) was measured by the formula: weight (kg)/ height (m2). Physical activity was assessed by the number of steps made daily using Omron Walking style III step counter HJ-203-EK pedometer. Study subjects measured the number of steps made in three days, and then calculated the mean number of steps per day. Body composition, fat and muscle
Results.
Patients with hypertonic disease and type 2 diabetes mel-litus were comparable in terms of age (57.2 ± 11 vs. 55.1 ± 4.6 years old, p=0.49). Blood pressure values were reliably higher in study group vs. control group. Thus, SBP and DBP in hypertonic disease and diabetes mellitus group were 136.5 ± ± 12.6 and 86.5 ± 9.2 mm Hg, while in control group, SBP and DBP were reliably lower: 114.5 ± 8.6 (pSBP1-2 = 0.001) and 66.5 ± 8.7 (pDBP1-2 = 0.001). It should be noted that in 44% patients with hypertonic disease, blood pressure failed to achieve target values and was above 130/80 mm Hg, despite standard therapy conducted. Also, patients with hypertonia and diabetes had high glucose and cholesterol levels (Table 1).
Table 1. - Indicators of carbohydrate metabolism and cholesterol in patients with hypertension and type 2 diabetes mellitus
Index Hypertension + Diabetes Millitus (n=25) M±d Control group (n=18) M±d X2 P
Total cholesterol, mmol/l 5.4±1.1 4.2±0.9 0.001
HDL cholesterol, mmol/l 1.25±0.6 1.89±0.7 0.01
TG, mmol/L 1.8 ±1.1 1.34±0.9 0.153
LDL cholesterol, mmol/l 3.4 ±1.0 2.4±1.0 0.002
Glucose, mmol/l 7.3 ±3.3 4.3±1.6 0.001
HbA1C,% 7.0 ±0.8 4.7±0.7 0.01
Body mass index, waist circumference and content of visceral fat were reliably higher in patients with hypertonic disease and diabetes vs. control group (Table 2).
Table 2.- Anthropometric indicators of the examined patients
Index Hypertension + Diabetes Millitus (n=25) M ± d Control group (n=18) M ± d X2 P
Body mass index, kg/m2 32.3 ± 6.9 19.2 ± 4.1 0.03
Waist measurement, cm 105 ± 16.5 73 ± 9.1 0.02
Hips, cm 118.9 ± 13.4 101 ± 5.8 0.7
Adipose tissue,% 41.7 ± 9.2 30.9 ± 4.2 0.06
Visceral fat,% 12.3 ± 4.7 7.2 ± 2.3 0.03
Muscle,% 24.5 ± 5.5 30.7 ± 3.9 0.06
Dynamometry, kg 31.3 ± 11.3 34.2 ± 6.5 0.06
Caliperometry, mm 27.4 ± 11.3 23.4 ± 7.6 0.9
Control group subj ects were undertaking reliably more physical activities and walked reliably longer distances on a daily basis.
Table 3.- Behavioral risk factors in patients with combined course of hypertension and type 2 diabetes mellitus and in the control group
Index Hypertension + Diabetes Millitus (n=25) Control group (n=18) X2 P
1 2 3 4
Age, years 57.2 ± 11 55.1 ± 4.6 0.451
Smoking, n(%) 3(12%) 2(11.1%) 0.0002 p=0.657
Alcohol abuse, n(%) 1(4%) 0(0%) 0.017 p=0.581
mass ratio were studied using bioelectric impedance method using Omron Body Composition Monitor BF511. Muscle and fat tissue ratio was measured together with visceral fat share. Sleep disorders were assessed using the International Sleep Disorder Classification, edition 3, developed by the American Academy of Sleep Medicine, 2014 and Epworth Sleepiness Scale. Statistical analysis was performed using SPSS software, version 17.0. The data corresponded to normal distribution and were presented as the mean value and standard deviation; intergroup difference reliability was assessed by Student's test, and sign incidence was compared by x2 test.
1 2 3 4
Regular workouts, n(%) 5(20%) 13(72.2%) 0.273 p=0.0008
Walking with small children, n(%) 1(4%) 3(16.7%) 0.046 p=0.190
Cleaning of the apartment, n(%) 22(88%) 1 (77.8%) 0.019 p=0.314
Walking on foot per day, meters, steps 3292 ± 245 6553±178 0.0001
Patients with hypertonic disease and diabetes mellitus tients had more frequent sleep disorders in the first years after more often reported night-time meals (Table 4). Female pa- labor. Table 4. - Risk factors for sleep disorders
Questions Hypertension + Diabetes Millitus (n=25) n(%) Control group (n=18)n(%) X2 P
Night / shift work 15(60%) 13(72.2%) 0.016 p=0.308
Daytime sleep 6(24%) 1(5.5%) 0.061 p=0.114
Eating at night 8(32%) 0(0%) 0.165 p=0.008
Sleep disturbances in the first years after childbirth 21(84%) 10(55.5%) 0.098 p=0.044
Abuse of caffeinated drinks 3(12%) 1(5.5%) 0.012 p=0.438
Frequent changes of time zones 0(0%) 0(0%) 0
Sleep disorders were observed in both study groups, irritability, frequent mood swings (Table 5). According to Ep-however, patients with hypertonic disease and type 2 diabe- worth Sleepiness Scale, sleepiness in patients with combined tes mellitus reported reliably more difficulties in falling asleep course of hypertonic disease and type 2 diabetes mellitus was and early rising, and consequently, behavioral problems were 6.7 points, while in control group of healthy volunteers, the predominant among daily symptoms: increased emotionality, score was 4.1 points. Table 5.- Assessment of sleep disorders by the American Academy of Sleep Medicine
Characteristics of sleep disorders and their daily manifestations Hypertension + Diabetes Millitus (n=25)n(%) Control group (n=18)n(%) X2 P
1 2 3 4
Sleep assessment
Difficulty falling asleep 10(40%) 2(11.1%) 0.1 p=0.038
Difficulties in maintaining a continuous sleep 11(44%) 6(33.3%) 0.50 p=0.480
Early Awakenings 18(72%) 7(38.9%) 4.60 p=0.032
Inability to fall asleep according to the usual routine of the day 13(52%) 6(33.3%) 0.82 p=0.366
1 2 3 4
Daytime Symptoms
Nausea / vomiting 2(8%) 0(0%) 0.04 p=0.332
Violation of attention, concentration or memory 13(52%) 8(44.4%) 0.03 p=0.857
Violations in the social, family or professional sphere 5(20%) 3(16.7%) 0.002 p=0.553
Mood disturbance 11(44%) 4(22.2%) 0.051 p=0.124
Daytime sleepiness 10(40%) 8(44.4%) 0.08 p=0.983
Behavioral problems 13(52%) 4(22.2%) 0.09 p=0.047
Reducing motivation / energy / initiative 17(68%) 7(38.9%) 0.083 p=0.056
Propensity to errors 10(40%) 5(27.8%) 0.016 p=0.309
Concentration on dissatisfaction with your sleep 7(28%) 4(22.2%) 0.004 p=0.475
Frequency and duration of symptoms
Sleep disorders and associated daytime symptoms are present at least 3 times a week 15(60%) 4(22.2%) 0.141 p=0.015
Sleep disorders and associated daytime symptoms persist for at least 3 months 12(48%) 5(27.8%) 0.042 p=0.154
Other causes of sleep disorders
Night awakenings, not explainable by sleep disorders 2(8%) 0(0%) 0.035 p=0.332
Discussions:
It is well-known that sleep duration and quality disorders adversely affect health condition and are associated with risk of chronic non-infectious diseases [2]. Experts from American Academy of Sleep Medicine demonstrated that in order to maintain healthy condition, night-time sleep should be at least 7-8 hours [6].
Relation between night-time apnea and development risk of hypertension, and with resistant course of hypertension is well-studied in the literature [8]. At the same time, it is confirmed that even if no obstructive sleep apnoe is observed, short sleep duration, insomnia, restless legs syndrome, shift-work are connected to hypertension [7]. It is established that sleep disorders may cause increased blood pressure as early as in adolescence [11]. Chronic insomnia is considered by several authors as hypertension development risk factor [16]. Vgontzas A. N. et.al. In the study among
1741 male and female patients, it was established that sleep duration for less than 5 hours is associated with hypertension development risk. In NHANES study, 4810 patients without arterial hypertension were followed-up (aged 25-74 years). Within observation period for 8-10 years, close relation between hypertonic disease and sleep duration less than 5 hours was observed [2]. One of the potential mechanisms of hypertension development in sleep disorders are inevitable circadian activity disorders in sympathetic and parasym-pathetic systems. In normal physiological circadian cycle of vegetative nervous system activity during sleep, blood pressure is reduced by 10% and more [17]. Impaired function of hypothalamo-pituitary-thyroidal axis is as important, and, consequently, impairment of circadian and ultradian rhythm of cortisol production [19]. These pathogenetic mechanisms may cause both development of hypertension, and development and maintenance of insomnia itself.
Hypertension and type 2 diabetes mellitus are the diseases which are most commonly observed simultaneously. Yadav D. And Cho K. H., having analyzed the results of several epidemiologic studies, reached the conclusion that the relation between sleep disorders and type 2 diabetes mellitus risk is seen as U-shaped curve. Both high sleep duration and its shortness are associated with the risk of type 2 diabetes mellitus [14]. These data are correlated with the results obtained in the analysis of disorders performed by Kim C. E. et al. In their work, investigators demonstrated that sleep duration of less than 6 hours is associated with waist increase in both male and female patients, and with metabolic syndrome development in male patients only. Sleep duration of more than 10 hours is also associated with waist increase, growth of triglycerides and development of metabolic syndrome in both male and female patients. In women, increased sleep duration was also associated with increased glucose levels and reduction of high-density lipoprotein cholesterol [17]. Relation between development risk of diabetes mellitus and sleep disorders was demonstrated in one Japan study among 38,987 patients. The relation was observed in only young and middle-aged patients, while in elderlies, no reliable evidence was obtained [21]. Possibly, in elderlies, other pathogenetic mechanisms are involved. It is also known that in patients with existing diabetes mellitus, sleep disorders impair glycaemia control [20].
Our study demonstrates that patients with hypertonic disease and type 2 diabetes mellitus were reliably more often subject to such sleep disorders as night-time meals and sleep disorders in the first years after giving birth. At the same time, sleep disorders in patients with hypertonia and diabetes was reliably more commonly manifested as only difficulties while falling asleep and early rising. However, these disorders consequently caused day-time symptoms and behavioral disorders. Our work is different from previous studies in that it analyzes not only sleep duration and quality, but also those day-time symptoms the patients had. It is demonstrated that it were day-time symptoms that helped distinguishing sleep disorders in patients with hypertonic disease and diabetes mellitus and those in control group.
Conclusion
1. In patients with hypertonic disease and type 2 diabetes mellitus, disorders were more frequent in falling asleep and early rising, while impairment of usual sleep-awake regimen and inability to maintain continuous sleep were observed with similar frequency in both groups.
Prospective trends. Assessment and development of sleep disorder correction methods is an important stage to prevent development and severe course of hypertonic disease and diabetes mellitus.
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