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 Table of Contents  
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 45-52

Assessment of Sleep and Quality of Life Among Chronic Obstructive Airways Disease Patients

1 Department of Psychiatry, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India
2 Department Respiratory Medicine, ESIC Medical College, Faridabad, Haryana, India
3 Department of Community Medicine, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Ruchi Sachdeva
Department Respiratory Medicine, ESIC Medical College, Faridabad, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jacp.jacp_20_17

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Objective: To assess sleep and quality of life among chronic obstructive airway disease patients. Materials and Methods: Patients with primary, mild-to-moderate, stable chronic obstructive airways disease [asthma and chronic obstructive pulmonary disease (COPD)] on treatment visiting outpatient department of a government hospital were interviewed using a predesigned, pretested, semi-structure schedule. The patients were then administered standardized Pittsburgh sleep quality index (PSQI), St. George’s respiratory questionnaire (SGRQ), and Epworth sleepiness scale (ESS) questionnaires. Patients with any other known chronic disease, chest deformity, or long-term oxygen therapy were excluded. Using purposive sampling frame, 120 chest patients (asthma and COPD) and in addition, 30 ambulatory patients without having any underlying chronic respiratory diseases were also recruited for comparison purpose. Results: Mean age was 50.2 years. Mean duration of sleep during night was 5.40 h [±1.6; 95% confidence interval (CI) = 4.98–5.82] for patients with COPD; 5.53 h (±1.6; 95% CI = 5.11–5.95) for patients with asthma, and 6.97 h (±1.0; 95% CI = 6.57–7.36) for control patients (P < 0.001). It was noticed that 63.3% of control patients had at least 6 h of night sleep in comparison to 23.3% of chest patients (P < 0.01). Good PSQI score (up to 5 points) was found in 86.6% of control patients while it was found only in 35.0% of chest patients (P < 0.01); mean PSQI score among asthma was 8.08, 8.06 (COPD), and 3.46 among control patients, respectively. All the control patients (100%) reported good score for quality of life while chest patients reported good score for SGRQ (activity, impact, and symptoms) as 64.1, 83.3, and 82.5%, respectively (P < 0.01). Based on ESS, none of the patients complained of daytime sleepiness. To conclude, poor sleep was noticed in our study sample.

Keywords: Asthma, chest, chronic respiratory diseases, COPD, ESS, MMSE, PSQI, quality of life, SGRQ, sleep quality, smoking, tobacco

How to cite this article:
Malhotra M, Sachdeva R, Sachdeva S. Assessment of Sleep and Quality of Life Among Chronic Obstructive Airways Disease Patients. J Assoc Chest Physicians 2018;6:45-52

How to cite this URL:
Malhotra M, Sachdeva R, Sachdeva S. Assessment of Sleep and Quality of Life Among Chronic Obstructive Airways Disease Patients. J Assoc Chest Physicians [serial online] 2018 [cited 2021 Oct 26];6:45-52. Available from: https://www.jacpjournal.org/text.asp?2018/6/2/45/232963

  Introduction Top

Asthma and chronic obstructive pulmonary disease (COPD) are important public health respiratory problems over the world. The global prevalence of asthma and COPD in general population ranges from 1 to 18% and 3 to 11%, respectively.[1] India is currently harboring a staggering 57,000,000 people suffering from obstructive airway diseases with at least 35% of adult population consuming tobacco in some form.[2],[3] Although chronic respiratory diseases affect primarily the respiratory tract/lungs but lately have been found to have many systemic effects and complications related to cardiovascular, musculoskeletal, neurological system, with nutritional, and metabolic effects.[4],[5]

Sleep-related disturbances and insomnia have been shown to be higher in patients with COPDs than that in the general population, ranging between 50 and 70% of patients reporting difficulty in initiating or maintaining sleep, or having poor sleep quality.[6] Disturbed sleep has been found to be associated with more severe disease, frequent exacerbations, and increased mortality. Poor sleep quality also affects the quality of life in COPD and patients with asthma.[7],[8] There are limited studies performed in Indian context exploring the sleep quality pattern among chronic respiratory disease patients. With this background a study was undertaken to determine sleep and quality of life among primary obstructive airway disease as well as control patients visiting a government hospital.

  Materials and Methods Top

The interview schedule captured sociodemographic details and consisted of mix of self rating response items elicited in local language by researcher followed by treatment, advice, and counseling. Sociodemographic variables included age, gender, marital status, education, tobacco consumption/smoking, duration of illness, history of hospitalization of at least 24 h in past 1-year, sleep pattern, and duration. Some of the details, especially duration of sleep, daytime sleepiness, etc. was re-checked with the patient’s accompanying spouse, if available. The patients were then assessed using standardized Pittsburgh sleep quality index (PSQI), St. George’s respiratory questionnaire (SGRQ), Epworth sleepiness scale (ESS), mini mental status examination (MMSE). Patients with any known chronic liver, kidney, heart, neurological disease, malignancy, chest deformity, or long-term oxygen therapy were excluded.

A study was performed in Hindu Rao Hospital, New Delhi a government teaching hospital among ambulatory, stable, adult patients in a comfortable, confidential, and nonjudgemental manner. Using purposive sampling frame, 120 diagnosed chest patients (asthma and COPD) on treatment visiting outpatient department were clinically evaluated and interviewed using predesigned, pretested, semi-structure interview schedule during the period January to March 2014 after seeking informed written consent of patients and ethical consideration. In addition, 30 ambulatory patients without having any underlying chronic respiratory disease reporting for common cold/muscular pain/generalized weakness, etc., were also mobilized for comparison purpose.

Brief on study instruments.

Pittsburgh sleep quality index

Sleep quality was measured using the PSQI, a self-rated subjective questionnaire comprising 19 questions that generate seven "component" scores (sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction).[9] Each component score is marked from 0 to 3, with a maximum total score of 21 and a minimum score of 0. The sum of the component scores yields a global PSQI score. A global score up to 5 indicates "good" overall sleep quality, whereas a score >5 indicates "poor" sleep quality with a diagnostic sensitivity and specificity of 89.6 and 86.5%, respectively. In comparison with other tools to measure sleep, the PSQI has undergone extensive psychometric evaluation. It has been shown to have high test–retest reliability and construct validity.

St. George’s respiratory questionnaire

It is designed to measure impact on overall health, daily life, and perceived well-being in patients with obstructive airways disease. It covers three domain-symptoms, activity, and impact. It addresses the frequency of respiratory symptoms and patient’s current health state (i.e., how they are these days). The activity score measures disturbances in daily physical activity. The impacts score covers a range of disturbances of psycho-social function.[10] Score ranges from 0 to 100 with zero indicating best and higher score indicating worse state.

Mini mental status examination

It has 22 items, which examines various cognitive capacities (orientation to time and place, memory, attention, concentration, recognition of objects, language function, comprehension and expressive speech, motor functioning, and praxis). The total score is 30 with higher score indicating worse condition. Hindi adaptation of the MMSE instrument was used in this study.[11]

Epworth sleepiness scale

The ESS is intended to measure daytime sleepiness.[12] The patients were interviewed to rate their probability of falling asleep on a scale of 0–3 with increasing probability for eight situations that most people engage during their daily lives, though not necessarily every day. The scores for the eight questions are added together to obtain a single number. A number in the 0–9 range is considered to be normal, while a number in the 10–24 range indicates that expert medical advice should be sought.

Statistical and data analyses

All categorical variables were expressed as frequencies and percentages, and continuous variables were expressed as mean and standard deviation. For the purpose of analysis, PSQI score of 0 and 1 (better score) was classified into good and score of 2 and 3 as worse. Same concept was applied to other scales as applicable. Among all the patients, it was found out that average night sleep was 5.7 h; therefore, sleep duration in the night was dichotomised into less than and more 6 h duration to explore association with other co-variables. There were no missing values. Descriptive statistics and association between variables were determined using chi-square test while the strength of association with co-variables was measured by contingency coefficient and considered significant at P < 0.05. Data management was undertaken using the Statistical Package for the Social Sciences version 16.0 software (IBM, Chicago, USA). Some of the inherent limitations of this study include hospital based convenience sampling; sleep duration was assessed on subject recall that is prone for bias; in addition, patients could not undergo polysomnography evaluation due to resource constraints.

  Results Top

Background details

Out of a total of 150 patients, there were 60 (40%) patients with asthma; 60 (40%) patients with COPD; and 30 (20%), control patient. Overall mean age was 50.2 years [chest patients had mean age of 51.0 (±13.4) years while control patients were 47.2 (±12.7) years old (P > 0.05)]. [Table 1] shows the background information of patients.
Table 1: Background information of study patients (chest and control patients)

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Sleep duration

Mean duration of sleep during night was 5.40 h [±1.6; 95% confidence interval (CI): 4.98–5.82] for patients with COPD; 5.53 h (±1.6; 95% CI: 5.11–5.95) for patients with asthma; and 6.97 h (±1.0; 95% CI: 6.57–7.36) for control patients (P < 0.001). Association between demographic variables, sleep quality, and sleep duration is shown in [Table 1]. Significantly higher proportion of control patients had positive feature in comparison to chest patients, that is, 63.3% of control patients had more than 6 h of night sleep in comparison to 23.3% of chest patients (P < 0.01).

Sleep quality

Good PSQI score (up to 5) was found in 86.6% of control patients while it was found only in 35.0% of chest patients (P < 0.01). Mean PSQI score was 8.08 (asthma), 8.06 (COPD), and 3.46 (control) patients, respectively, with higher score indicating worse condition. On considering duration of illness among chest patients into <2 and ≥2 years, mean PSQI score was 6.5 and 8.19 for asthma while it was 8.2 and 8.0 for patients with COPD. With regard to presence or absence of psychiatric co-morbidity among chest patients, average PSQI score was 9.5 (present) and 7.98 (normal) among asthma while it was 12.5 (present) and 7.75 (normal) patients with COPD. On considering tobacco consumption, overall mean PSQI score was 7.20 for tobacco consumer and 7.08 for nonconsumer. Component wise PSQI score (good/worse) is shown in [[Figure 1] and [Figure 2]], respectively.
Figure 1: Proportion of asthma patients (n = 60) with good and worse PSQI score

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Figure 2: Proportion of COPD patients (n = 60) with good and worse PSQI score

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Quality of life

All the control patients (100%) reported good score for quality of life (SGRQ-activity, impact and symptoms) while only 64.1, 83.3, and 82.5% of chest patients reported good score for SGRQ, respectively (P < 0.01). Mean values of quality of life (SGRQ score) is shown in [Table 2].
Table 2: Quality of life score among all study patients

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Duration of night-sleep, PSQI and SGRQ score was significantly associated (P < 0.01) with type of patients (chest vs. control). Further association was explored for sleep duration (less than and >6 h) with sleep quality. Details are shown in [Table 3] and [Table 4]. Quality and quantity (duration) of sleep is an inter-linked concept. Higher proportion of patients with poor PSQI score (poor quality) slept for <6 h while the inverse, that is, higher proportion of patients with good PSQI score (good quality) slept for >6 h. This is adequately reflected by moderately incremental values of contingency coefficient, a factor of strength of association.
Table 3: Association of sleep quality with sleep duration (<6 h) among patients

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Table 4: Association of sleep quality with sleep duration (>6 h) among patients

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Based on MMSE, all the chest and control patients had normal cognitive capacities. Similarly on ESS, none of the patient complained of daytime sleepiness.

  Discussion Top

A descriptive study was undertaken to assess subjective sleep pattern among ambulatory, mild-to-moderate, stable, primary cases of obstructive airway disease (asthma and COPD) on treatment presenting as follow up visits at outpatient department of a mid level government hospital of Delhi, India. Our study showed significant differences reflecting poor quality of sleep and quality of life among chronic obstructive airway disease (asthma and COPD) patients in comparison to controls. Among chest patients, it was noticed that only 23.3% had at least 6 h of night sleep while 65% had poor PSQI global score (>5 points); 35.8, 16.6, and 17.5% had poor SGRQ score related to activity, impact and symptoms, respectively. All the patients were nonobese, had normal cognitive capacity with none reporting daytime sleepiness. Globally it is known that poor sleep quality is observed more frequently among patients with COPD; however, in our study COPD and patients with asthma had similar poor results. Quality of sleep can be improved by ensuring compliance to treatment, management of co-morbidities including gastro esophageal reflux, oxygen therapy, providing training for inhaler technique, counseling, life style changes, behavior change communication, avoidance of trigger factors and rehabilitation.[13],[14],[15],[16],[17],[18]

On review of literature, Nunes et al.[7] reported that 70% of patients with COPD had poor sleep quality; and the quality of sleep was the major determinant of quality of life in those patients. In another recent study more than half of the patients with COPD experienced poor sleep quality. The most common sleep complaints included getting up for the bathroom, waking up at night or in the early morning, and coughing or snoring loudly.[19] In a study by Scharf et al.[20] sleep quality was also associated with quality of life and sleep disturbance predicted poor survival in patients with COPD.[21] The factors resulting in sleep disturbance are not well understood. There are multi-factorial causation and/or determinants of a particular health state yet conservatively it can be commented that quality of sleep was disproportionately more affected than quality of life among our sampled asthma and patients with COPD. With regard to quality of life, similar but slightly better status has been reported among COPD in a community based study conducted by Ahmed et al. in Aligarh, Uttar Pradesh.[22] The mean SGRQ score in this community based study was 49.54 (symptom score), 41.47 (activity score), 33.58 (impact score) and 38.89 (total score). In our hospital based study, the mean score (poor condition) was found to be slightly higher [Table 2].

It is noted that according to Global Adult Tobacco Survey, prevalence of tobacco consumption among adults in India has decreased by 6.0% point from 35% (2009–10) to 28.6% (2016–17).[23] Based on these, there were 274.9 million tobacco users with 163.7 million users of only smokeless tobacco, 68.9 million only smokers and 42.3 million users of both smoking and smokeless tobacco in the country with mean age at initiation being 18.9 years. The survey also reported that 38.7% [rural (44.4%) to urban (27.9%)] of adults were exposed to second-hand-smoke at home. According to Census 2011, two third of households in country are using firewood/crop residue, cow dung cake/coal, etc., in their kitchen. The tobacco epidemic, environmental pollution, other risk exposure, and poor health practices worldwide and particularly in developing country along with extensive use of bio fuel is now presenting itself with its adverse and diverse consequences in community and at health facilities. This observation is further substantiated, as COPD accounted for second most common reason for respiratory morbidity and mortality in India after tuberculosis.[24]

Sleep is a physiological process essential to life yet one-third of adult’s reports difficulty in sleep and the prevalence of insomnia in general population ranges between 10 and 48%.[25],[26],[27] Among our hospital based study (chest plus control) patients, overall 54.6% (PSQI score: >5) reported the same. The pattern of sleep and wakefulness in different patients is known to vary with their age, demands of their occupation, their physiological and psychosocial characteristics, psychiatric illness, and some types of physical illness.[28] In the last couple of decades, there has been a growing attention to sleep and sleeplessness related problems across the globe. A new determinant of adverse sleep quality is being observed with emergence and constant encroachment in human life by information technology (smart phones, internet) tools and media. This interest is mainly due to the recognition that sleepiness and fatigue are becoming endemic in the population.[29]

Quality of sleep can be assessed subjectively by administration of questionnaire, clinical interviews and sleep diaries. The objective sleep quality is determined by polysomnography (laboratory or home based) and actigraphy; however, it is more challenging considering the availability of resources. Even in mild-to-moderate patients with COPD, polysomnography evaluation has demonstrated poor quality and low duration of sleep[30] as observed in our study too.

In conclusion, this study can be considered to be unique, because the influence of chronic respiratory ailments on sleep quality and quality of life was assessed simultaneously using diverse globally acknowledged measurement scale upon clinical confirmation using standard definitions. The findings are suggestive of significantly impaired sleep quality among chronic obstructive airway disease patient’s in-comparison to control patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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