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Presentation & Risk Factors

The presentation of OSA is very heterogeneous.

Presenting symptoms include: excessive sleepiness, fatigue, snoring, witnessed breathing cessation, sleep disruption and frequent awakenings, nocturia, disruption of concentration, memory and executive functions, depressed mood, or decreasing work performance. Common risk factors include male gender, age over 50 years, overweight and obesity, excess alcohol consumption, post-menopause (females). Lifestyle/weight loss advice is an important part of management. The prevalence of OSA is increased in patients with type 2 diabetes, those with hypertension and cardiovascular disease, and in patients prescribed sedative medications.

The clinical presentation of OSA is very heterogeneous ranging from those with loud snoring, frequent episodes of apnoea and excessive daytime sleepiness through to those who are asymptomatic. However more severe OSA is likely in those with risk factors and symptoms so it is important to consider OSA in obese patients who present with a history of daytime sleepiness, or tiredness, snoring and BMI > 30 kg/m2. OSA needs to be distinguished from simple snoring which is the simplest form of sleep-disordered breathing.

Patients with positional OSA (the majority of apnoeas can be attributed to a supine sleep position) tend to be less obese, and to be younger than non-positional patients.1

Approximately 30-50% of OSA patients report clinically significant insomnia symptoms, and approximately 30-40% of patients with insomnia fulfil diagnostic criteria for OSA.2, 3 The combination of OSA and insomnia results in greater morbidity, including daytime impairments (fatigue, concentration difficulties, reduced motivation), and depressive symptoms compared to patients with either OSA or insomnia alone.2, 4 The presence of insomnia symptoms in OSA patients reduces the acceptance and use of CPAP therapy. Recent RCT evidence has demonstrated that initial treatment with cognitive behavioural therapy for insomnia improves insomnia symptoms and may increase subsequent acceptance and use of CPAP therapy in patients with co-morbid OSA and insomnia.5 The Insomnia Severity Index is a simple self-report measure of insomnia severity; a score of ≥15 is indicative of clinically significant insomnia, which can be treated with cognitive behavioural therapy, even in the presence of OSA.6, 7

OSA can also overlap with other sleep disorders including restless legs/ periodic limb movements that may disturb sleep and require adjunctive therapy.

History, physical examination, and questionnaires including the OSA508, Epworth Sleepiness (ESS)9, STOP-Bang10 questionnaires, are best suited to establish complaints and comorbidity factors.

Table. Risk factors for OSA11

Simple Snoring

  • Affects 30% of population
  • Vibration in the nose and pharynx
  • Socially disruptive but no medical complications


  • Affects 20% of middle-aged population
  • Repetitive collapse of the oropharynx
  • Neurocognitive and cardiovascular complications

The prevalence of OSA (See Epidemiology) is less frequent in pre-menopausal women12 and increases with age13 and obesity, which has to be addressed in the management plan (See Management of Risk Factors, and Treatment Options).

Table. Risk factors for OSA14

  • Gender: males
  • Age: over 50 years
  • Overweight, obesity and metabolic conditions including glucose intolerance, insulin resistance, and type 2 diabetes
  • Excess alcohol consumption
  • Sedative medication
  • Opioids
  • Smoking
  • Sleeping in supine position
  • Tonsillar hypertrophy
  • Nasal obstruction
  • Craniofacial abnormalities, e.g. retrognathia
  • Thyroid disease
  • Neuromuscular disease
  • Insomnia
  • Family history including genetic factors related to jaw morphology
  • Post-menopause (females)

AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset

Quick links


  1. Morgenthaler TI, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006;29:1031
  2. Sweetman A, et al. Co-Morbid Insomnia and Sleep Apnea (COMISA): Prevalence, Consequences, Methodological Considerations, and Recent Randomized Controlled Trials. Brain Sci 2019;9(12):371
  3. Sweetman A, et al. Developing a successful treatment for co-morbid insomnia and sleep apnoea. Sleep Med Rev 2017;33:28-38
  4. Lang CJ, et al. Co‐morbid OSA and insomnia increases depression prevalence and severity in men. Respirology 2017;22(7):1407-15
  5. Sweetman A, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with co-morbid insomnia: A randomized clinical trial. Sleep 2019;42(12)
  6. Sweetman A, et al. Developing a successful treatment for co-morbid insomnia and sleep apnoea. Sleep Med Rev 2017;33:28-38
  7. Bastien CH, et al. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med 2001;2(4):297-307
  8. CL Chai-Coetzer, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnea in primary care. Thorax 2011;66:3-219
  9. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14(6):540-5
  10. Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anaesthesiol 2009;22(3):405-11
  11. RACGP gplearning ‘Obstructive Sleep Apnoea'
  12. Wimms A et al. Obstructive Sleep Apnea in Women: Specific Issues and Interventions. Biomed Res Int 2016;764837
  13. Ralls FM et al. Roles of gender, age, race/ethnicity, and residential socioeconomics in OSA syndromes. Curr Opin Pulm Med 2012;18(6):568-73
  14. RACGP gplearning ‘Obstructive Sleep Apnoea'