How Common Is Persistent Excessive Daytime Sleepiness in CPAP-Treated OSA?

A German population study explored the prevalence and incidence of residual excessive daytime sleepiness in patients with CPAP-treated OSA.

Persistent residual excessive daytime sleepiness (rEDS) in patients with obstructive sleep apnea (OSA) receiving primary continuous positive airway pressure (CPAP) therapy has a small but noteworthy prevalence and incidence in the German population, with twice as many men affected by this condition, according to findings of a large German study reported in Sleep Epidemiology.

Excessive daytime sleepiness has been found to persist in some patients using primary CPAP therapy for OSA. Researchers in Germany sought to estimate the overall prevalence and incidence of (rEDS) as well as the age- and gender-specific prevalence and incidence of rEDS in patients with CPAP-treated OSA, among the German population. Additionally, the investigators sought to describe clinical and demographic characteristics of patients with CPAP-treated OSA identified as having rEDS.

The retrospective, cross-sectional, observational, population-based study utilized a German health claims dataset, the InGef database. The dataset, which included more than 4 million insured individuals with 69 statutory health insurances (SHIs), comprised a 5% sample of the German SHI population. Data were analyzed using an expert-opinion-based diagnostic scheme to determine data indicators for rEDS and for EDS not satisfactorily treated by the primary OSA therapy.

Investigators identified 1298 patients in the dataset receiving CPAP therapy for OSA who showed indicators of rEDS in 2016, for a prevalence rate of 41.1 (95% CI, 38.9-43.4) per 100,000 individuals (which researchers estimated to amount to 34,107 individuals in the German population.). Additionally, a total of 203 new cases (ie, incident patients) were identified in the 2016 dataset, which led to an annual incidence of 6.4 (95% CI, 5.6-7.4) per 100,000 individuals (an estimated 5327 individuals in the German population). The researchers also found that in the year prior to the initiation of CPAP therapy, 46% of patients analyzed received antidepressants, 45% were undergoing psychotherapy, and 58% of employees were unable to work for 71 days, on average, per year.

Patients who were ‘identified with indicators of residual EDS showed a high socioeconomic burden potentially leading to an increased demand of [health care] services and incapacity for work.’

Investigators also conducted an additional analysis to determine the demographic and clinical characteristics of patients with CPAP-treated OSA and clear indicators of rEDS. A total of 4158 individuals from the dataset met specific inclusion criteria for this analysis. The mean age of this patient cohort was 61 years, with 85% of individuals at least 50 years of age. Moreover, rEDS occurred twice as often in men than in women (68% vs 32%, respectively. The most commonly reported comorbidities were hypertension, back pain, and depressive episodes. At 1 year prior to initiation of CPAP, patients reported using the following health care resources: antidepressants; psychotherapy and behavioral therapy; and visits to such specialists as neurologists, radiologists, ear-nose-throat specialists, surgeons, psychiatrists, psychotherapists, and pulmonologists.

This study had several limitations. Due to the absence of an explicit ICD-10 code for rEDS in OSA, there was a high degree of uncertainty in the identification of patients with rEDS. Further, because the database did not include clinical data, such as scores from the Epworth Sleepiness Scale, the researchers were unable to clinically validate whether the patients included in the study were actually affected by EDS and also were unable to establish false-positive and false-negative rates.

Study authors concluded that patients who were “identified with indicators of residual EDS showed a high socioeconomic burden potentially leading to an increased demand of [health care] services and incapacity for work.” More attention needs to be given to recognize symptoms of rEDS in CPAP-treated patients with OSA and to differentiate these symptoms from psychiatric diseases such as depression, said study authors.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

This article originally appeared on Pulmonology Advisor


Nilius G, Kallweit U, Trümper D, Vogelmann T, Schubert T. Prevalence, incidence, and characteristics of CPAP treated OSA patients with residual excessive daytime sleepiness, as indicated by health-related data – a population representative study. Sleep Epidemiol. 2022;2:100044.  doi.10.1016/j.sleepe.2022.100044