ORIGINAL ARTICLE

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AN EXAMINATION OF AUSTRALIAN GENERAL PRACTITIONERS' KNOWLEDGE, ATTITUDES AND PRACTICES IN RELATION TO SLEEP DISORDERS

C Hassed¹ MBBS, FRACGP; J Antoniades¹ BSc (Hons); KM Jones¹ MT+D, PhD; S Rajaratnam² BSc, PhD; L Kiropolous² BSc Psych, PhD; M Naughton³ MBBS, FRACP; L Piterman¹ MBBS, FRACGP
¹Monash University Department of General Practice. (Craig Hassed, Josefine Antoniades, Kay Margaret Jones, Leon Piterman)
²Monash University School of Psychology and Psychiatry. (Shanta Rajaratnam, Litza Kiropolous)
³Monash University Department of Medicine; Alfred Hospital. (Matthew Naughton)

Address of correspondence: Dr Kay Jones, Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168. Tel: +6 3 9902 4485, Fax: +6 3 8575 2233, Email: kay.jones@monash.edu

Conflict of interest: None.

INTRODUCTION

Sleep has a vital role in optimal human functioning.¹ Sleep dysfunction is associated with diminished cognitive and motor performance, decreased health status, poor mental health and quality of life, and increased morbidity and mortality.² Over 1.2 million Australians suffer from a sleep disorder, representing an under-recognised public health problem^3,4 including driver fatigue which contributes to more than 25% of all road crashes in Victoria, Australia.⁵ Sleep disorders are classified into four major groups.⁶ This study focuses on Obstructive Sleep Apnoea (OSA) and Insomnia. OSA, characterised by “repetitive episodes of upper airway obstruction that occur during sleep, usually associated with a reduction in blood oxygen saturation”,⁶ has been estimated to have a prevalence between 9-24% in the general population. Insomnias are characterised by dissatisfaction with quality of sleep and/or insufficient sleep quantity and has a prevalence of 6-15%.⁷

Patients with a sleep problems approach their general practitioners (GPs),³ but in more than 50% of cases, sleep disorders are not diagnosed by GPs⁸ resulting in sub-optimal management. For example, one American study found that of 150 patients attending a sleep laboratory, 30% suffered from undiagnosed OSA, and had been prescribed sedative medications, increasing their risk of motor vehicle accidents.⁹ The American Driver Fitness Medical Guidelines and the Australian Medical Standards for Licensing both emphasize that drivers with OSA have a greater motor vehicle crash risk than individuals without OSA, and individuals with OSA become unsafe soon after cessation of continuous positive airway pressure (CPAP) due to non-compliance.^10,11 Hence, it appears that under-diagnosis as well as inappropriate management of sleep disorders compound the associated substantial health and safety consequences.

In general practice, insomnia is predominantly managed with pharmacological interventions with some patients referred to a specialist and few to allied health professionals.¹² Behavioural approaches appear to be under-utilised for a variety of reasons including a lack of knowledge¹³ and training¹⁴ despite training being successful in increasing identification and diagnosis rates.⁸

While efforts to improve detection, diagnosis and management of OSA and insomnia in primary care are needed, few studies have examined GPs’ attitudes, knowledge and clinical practices of sleep disorders. Examining such factors will offer a chance to identify gaps in GPs training and educational opportunities and barriers GPs may face in their day-to-day clinical practice. This pilot study aimed to examine GPs’ attitudes, knowledge and clinical practice behaviours as well as identify factors influencing detection, diagnosis and treatment of OSA and insomnia in Australian primary care setting using qualitative and quantitative methods.

METHODS

Mixed method

Quantitative data included demographic information and the Dartmouth Sleep Knowledge Questionnaire (DSKQ). Qualitative data were collected through one focus group and eight interviews.

Participants

A convenience sample was recruited using two methods: a letter of invitation circulated through the Monash University networks, and advertisements which were placed in metropolitan-based General Practice Divisions from September 2009 to February 2010. 15 GPs participated; seven in a focus group and eight in face-to-face interviews which was all conducted in Melbourne, Victoria.

Data collection and tools

GP demographic data were collected using a brief demographic questionnaire. In addition, the 24-item multiple-choice DSKQ was used to assess GPs’ knowledge of sleep disorders and management.¹⁵ DSKQ is a validated questionnaire developed for the purpose of assessing effectiveness of curriculum development and educational interventions in sleep medicine. Based on current literature and expert advice, a semi-structured interview schedule was developed with six sub-headings and was used for the focus group and interviews (Table 1). The focus group was led by an experienced moderator and all interviews were conducted by one member of the research team. All were conducted between October 2009 and April 2010, audio-taped and transcribed verbatim.

Table 1: Summary of interview protocol

Category	Summary of semi-structured interview schedule
General	Frequency and types of sleep disorders seen Patient groups
Attitudes	GPs attitude towards impact of sleep disorder, self-perceived skills in assessment and management. Factors which impact clinical practice behaviours as well as patient factors in relation to sleep disorders Sources of knowledge
Practices	Practices relating sleep history Prescription habits
Insomnia	Assessment and management practices and preferences Distinguishing types of insomnia
Obstructive sleep apnoea	Assessment, management and referral practices
Personal experience	Impact of personal experience with sleep disorders on clinical practice behaviours

Data analysis

Results from the DSKQ and demographic data were analysed using MS Excel 2007. Data was explored using descriptive statistics. Qualitative data were collated¹⁶ and analysed using thematic analysis, with a constant comparative method.¹⁷ Data were analysed and verified independently by two investigators and emerging themes were compared, discussed until consensus was reached. Themes, supported by key quotes, are used to illustrate the main findings.¹⁸

Ethics

This study was approved by the Monash University Human Research Ethics Committee. GPs expressing interest in the study were provided with an explanatory statement either via email, fax or post and were encouraged to seek clarification as required from the research team. If GPs wished to participate, they returned written informed consent form to the research team.

RESULTS

Demographic data: The sample comprised of 15 GPs; nine males (60%) and six females (40%) (M age=53.06, SD=7.96). Participating GPs had been practising for an average of 25.7 years (range=5-40 years). These results concord with the national distribution.^19,20

Dartmouth Sleep Knowledge Questionnaire

All participants completed the DSKQ, with a maximum score of 24, the average score was M=13.1 (54%) (SD=2.78) (Table 2).

Table 2: Percentage of correct answers on DSKQ item (n=15)

Question	Correct answer	Percentage correct
REM behaviour disorder is primarily associated with which of the following conditions?	Neuropathology	46.1
Cataplexy is best described by which of the following?	Loss of muscle tone induced by emotion	85.7
Which of the following conditions is most commonly associated with excessive daytime sleepiness?	Obstructive sleep apnoea	93.3
Optimal long-term treatment outcomes for chronic, primary insomnia are achieved with which of the following therapies?	Cognitive-behavioural therapy	85.7
A polysomnogram (sleep study) is required for the diagnosis of which of the following sleep disorders?	Obstructive sleep apnoea	93.3
Acute ingestion of alcohol just prior to sleep onset has the following effect:	Increases total sleep time for the first half of the night and decreases total sleep time for the second half of the night	57.1
Which of the following is the recommended treatment for moderate to severe obstructive sleep apnoea?	Nasal continuous positive airway pressure	100.0
Initial evaluation of a patient with an insomnia complaint should include which of the following?	Sleep Log	80.0
Major depressive disorder is primarily associated with which of the following sleep disturbances?	Hypersomnia/Insomnia	92.3
The standard objective measure of daytime sleepiness is:	Multiple Sleep Latency Test	7.6
A 45-year-old woman presents complaining of symptoms consistent with restless leg syndrome. These symptoms interfere with her ability to initiate and maintain sleep most nights. She also has complaints of excessive daytime sleepiness, despite sleeping 8-9 hours per night, and finds herself routinely dozing off unintentionally while reading. Which of the following is the most appropriate pharmacological treatment for her current symptoms?	Low dose sedating antidepressant at bedtime	85.7
REM sleep normally begins:	About 90 minutes after sleep onset	40.0
A normal sleeper is aroused briefly after every minute of sleep for 2 consecutive nights. Even with this manipulation, the subject averages 6 hours of sleep between arousals. What effect would these arousals have on performance and subjective sleepiness?	Decrements equal to someone with total sleep deprivation of 40–64 hours.	66.6
The locus of the primary (or dominant) circadian clock is	Suprachiasmatic nucleus	22.2
An individual is being assessed for complaints of fatigue. A Multiple Sleep Latency Test (MSLT) is administered and the patient produces an average sleep onset latency of 12 minutes. What is the best interpretation of this result?	The patient is moderately sleepy	66.6
A 17-year-old male presents with difficulty falling asleep until 3 am and difficulty awakening for school at 7 am. He sleeps normally from 3 am until noon, when permitted, and then has normal alertness during waking hours He is most likely experiencing which of the following?	Delayed sleep phase syndrome	50.0
During a routine paediatric clinic visit, a mother reports that she has been finding her 7-year-old son up and walking around at night. These episodes occur 1-2 hours after the patient goes to bed. Although the patient may answer his mother if she talks to him, he has no recollection of the event the next day. Which of the following sleep-wake stages is this disturbance most likely to arise from?	Stage 3/4	36.3
Disorders commonly presenting with excessive daytime sleepiness include all of the following except:	Acute sleep deprivation	18.1
Obstructive sleep apnoea has been associated with an increased risk of developing which of the following:	Alzheimer’s Disease	90.9
A 28-year-old woman with a history of depression and anxiety undergoes polysomnography as part of a research study examining sleep and depression. She is currently taking Lorazepam 0.5 mg TID. Benzodiazepines have been associated with which effect on sleep architecture?	Increase in sleep spindles	27.2
Which of the following statements best describes individual sleep need?	Sleep need is fixed at about 7.5–8 hours through adult life.	69.2
Which of the following most commonly characterizes sleep in older individuals?	The ability to maintain sleep declines	64.2
The leading cause of chronic insomnia is.	Major depressive disorder	53.8
All of the following statements regarding sleep-wake cycle/circadian rhythm are true except	Forward shift rotations (day-evening-night) produce greatest sleep disruption	46.1

Qualitative findings

1. Knowledge and attitudes about sleep disorders and their management

The majority of GPs described their knowledge as being fair to poor; particularly their knowledge about sleep architecture and physiology was lacking which may affect GPs’ ability to identify underlying issue to establish a diagnosis. GPs indicated there was a lack of succinct assessment material available which could improve detection of sleep disorders:

“…I am pretty sure everyone in here can actually ask questions appropriate to find out the person has a sleep problem and probably even detailing you know the magnitude. But I think our problem is often defining, what’s the underlying reason for it.”

These comments were supported by the results of the DSKQ, which indicated GPs’ knowledge of sleep architecture, physiological basis of sleep and more unusual sleep dysfunctions was limited.

GPs were aware of the risks associated with pharmacological medication use to manage insomnia and agreed that prescribing benzodiazepines was undesirable due to risks including addiction, abuse, falls and suicide, particularly in the elderly:

“...and you have to be very careful, because the risk of suicide is actually quite significant.”

Most GPs were aware of behavioural and psychological interventions. This was also reflected in DSKQ results, with 85% of GPs correctly responding to items about behavioural management of insomnia:

“...yeah. We will often go through all those things (stress management, relaxation, CBT) with the sleep. Because there are as you know all those things we have mentioned, there are actually sheets you can give them with all those things. So they know what they are when they go home.”

Despite high scores on the DSKQ relating to OSA, several GPs reported they felt they were not well informed about OSA:

“...I agree with you entirely because when I went through medicine, we never got taught anything really about sleep apnoea or anything.”