Prevalence of Insomnia Among Patients with Bronchial Asthma

Abstract

Background:
Insomnia is commonly reported in patients with asthma. However, the prevalence of insomnia and its relationship to asthma control have not been established.

Objective:
To determine the prevalence of insomnia in adults with asthma and to evaluate the association between insomnia and level of asthma control.

Methods:
This is a cross-sectional study of 200 patients recruited from pulmonary clinics at a tertiary care center. Adults (age ≥16 years) diagnosed with asthma by the primary treating physician were recruited over a 6-month period from December 2018 to May 2019. Asthma and insomnia severity were assessed using the Asthma Control Test and Insomnia Severity Index (ISI).

Results:
The mean age of participants was 51±17 years, and 67% were female. Insomnia (ISI score ≥10) was present in 46.5% of the participants. The severity of insomnia was inversely related to the level of asthma control: moderate-to-severe insomnia was more frequent in patients with uncontrolled asthma (43%) than in those with partially controlled asthma (25%) or well-controlled asthma (12%) (P < 0.05 for all comparisons).

Conclusion:
Insomnia is common among patients with asthma, especially those with suboptimal asthma control. Further investigations are required to more fully understand the complex relationship between asthma and insomnia.

Full text

ORIGINAL RESEARCH
Prevalence of Insomnia Among Patients with
Bronchial Asthma
Abdullah AL-Harbi
1–3
, Tammam Alanazi
1
, Hazim Alghamdi
1
, Meshal Alberreet
1
,
Abdulaziz Alkewaibeen
1
, Abdulrahman Alkhalifah
1
, Aamir Omair
1,4
, Mohammad Khan
1–3
,
Hamdan AL-Jahdali
1–3
1
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia;
2
Department of Medicine, Pulmonary Division,
King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia;
3
King Abdullah International Medical Research Center,
Riyadh, Saudi Arabia;
4
Department of Medical education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi
Arabia
Correspondence: Abdullah AL-Harbi, Department of Medicine, Pulmonary Division, Ministry of National Guard-Health Affairs, P.O. Box 22490, MC
1443, Riyadh, 11426, Saudi Arabia, Email harbia7@ngha.med.sa; draalharbi@yahoo.com
Background: Insomnia is commonly reported in patients with asthma. However, the prevalence of insomnia and its relationship to
asthma control have not been established.
Objective: To determine the prevalence of insomnia in adults with asthma and to evaluate the association between insomnia and level
of asthma control.
Methods: This is a cross-sectional study of 200 patients recruited from pulmonary clinics at a tertiary care center. Adults (age ≥16
years) diagnosed with asthma by the primary treating physician were recruited over a 6-month period from December 2018 to
May 2019. Asthma and insomnia severity were assessed using the Asthma Control Test and Insomnia Severity Index (ISI).
Results: The mean age of participants was 51±17 years, and 67% were female. Insomnia (ISI score ≥10) was present in 46.5% of the
participants. The severity of insomnia was inversely related to the level of asthma control: moderate-to-severe insomnia was more
frequent in patients with uncontrolled asthma (43%) than in those with partially controlled asthma (25%) or well-controlled asthma
(12%) (P < 0.05 for all comparisons).
Conclusion: Insomnia is common among patients with asthma, especially those with suboptimal asthma control. Further investiga-
tions are required to more fully understand the complex relationship between asthma and insomnia.
Keywords: prevalence, asthma, insomnia, asthma control, Insomnia Severity Index
Introduction
Asthma is a common inammatory respiratory disease characterized by intermittent symptoms of wheezing, dyspnea,
cough, and chest tightness, combined with variable airow obstruction, bronchial hyperresponsiveness, and chronic
airway inammation.
1,2
The prevalence of asthma varies worldwide, ranging from approximately 5% to 20% in most
countries.
3–7
Sleep disturbances and poor sleep quality are common among patients with asthma and are associated with poor
quality of life. The causes of sleep disturbance are multifactorial and related to poor asthma control, as well as associated
comorbidities, such as gastroesophageal reux disease (GERD), obstructive sleep apnea, chronic rhinitis, and
depression.
8–17
Insomnia is a frequent occurrence in patients with asthma and is characterized by difculty with falling
asleep, difculty maintaining sleep, awakening too early, and daytime impairment resulting from the disturbed sleep.
Insomnia symptoms have been reported in approximately one-third of patients with asthma, and the presence of these
symptoms has been associated with worse of quality of life, more severe asthma symptoms, and increased health care
utilization.
18
Nevertheless, limited data are available regarding the association between asthma severity and
insomnia.
19,20
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Journal of Asthma and Allergy Dovepress
open access to scientific and medical research
Open Access Full Text Article
Received: 19 October 2021
Accepted: 14 January 2022
Published: 29 January 2022

The objectives of this study were to determine the prevalence of insomnia among a sample of adults with asthma in
Saudi Arabia and to evaluate the relationship between insomnia and level of asthma control.
Materials and Methods
This cross-sectional study consisted of 200 adults with asthma recruited from pulmonary clinics at King Abdulaziz
Medical City in Riyadh, Saudi Arabia, from December 2018 to May 2019. All adults (age ≥16 years) with asthma
evaluated during the study period (n=222) were invited to participate in the study, but 22 declined. The diagnosis of
asthma was based on the primary treating physician’s diagnosis plus documentation of reversible airow obstruction on
spirometry with a positive bronchodilator response and/or positive methacholine challenge test.
1
Patients with the
following conditions were excluded from the study: known sleep-disordered breathing, depression, other psychiatric
illness, chronic obstructive pulmonary disease, interstitial lung disease, primary diagnosis of bronchiectasis, other chronic
lung disease, neuromuscular disease, heart failure, liver disease, and renal failure. Patients with a smoking history of >10
pack-years were also excluded from the study.
The level of asthma control was assessed using the validated Arabic version of the Asthma Control Test (ACT).
14–16
ACT is a validated instrument for assessing asthma control, with scores ranging from 5 to 25. Based on ACT scores, the
level of asthma control was classied into three groups: well-controlled, ACT = 20–25; partially controlled, ACT = 16–
19; and uncontrolled, ACT = 5–15.
17,18
Insomnia was assessed using the Arabic version of the Insomnia Severity Index (ISI).
21
ISI is a well-validated
instrument for evaluating insomnia symptoms. It consists of seven items, which assess falling asleep, difculty
maintaining sleep, waking up too early, dissatisfaction with sleep quality, daytime impairments resulting from the
sleep disturbance, sleep problems noticed by others, and distress caused by sleep difculties. Total ISI scores range
from 0 to 28, with scores ≥10 indicating the presence of insomnia with an 86.1% sensitivity and 87.7% specicity.
Based on nal ISI scores, the severity of insomnia was classied into four groups: no insomnia, ISI = 0–7; sub-
threshold insomnia, ISI = 8–14; moderate insomnia, ISI = 15–21; and severe insomnia, ISI = 22–28.
21,22
The study protocol was approved by the Institutional Review Board Committee at King Abdullah International
Medical Research Center (SP18/368/R), and all participants provided written informed consent.
Statistical Analysis
All analyses were conducted using the Statistical Package for Social Sciences (SPSS v. 25.0; Armonk, NY, USA). Mean
and standard deviation were used to summarize normally distributed data, whereas median and interquartile range were
used for non-normal distributions. Categorical data were summarized as frequency and percentage. Demographic and
clinical variables were compared between patients with and without insomnia using Student’s t-test or chi-square test, as
appropriate. Logistic regression analysis was used to identify risk factors associated with insomnia. P values <0.05 were
considered statistically signicant.
Results
Demographic and clinical characteristics of the study participants are detailed in Table 1. Insomnia (ISI ≥ 10) was
reported in 93 of 200 participants, for a prevalence rate of 46.5%. The insomnia group was predominantly female (73%),
with a mean age of 54 ± 16 years. Demographics, asthma duration, and degree of airow obstruction were not different
between patients with and without insomnia. Sleep duration was shorter (P = 0.01) and ACT scores were lower (P =
0.001) in the insomnia group than in the no insomnia groups.
The severity of insomnia differed across levels of asthma control. The prevalence of moderate or severe insomnia was
higher in patients with uncontrolled asthma (43%) than in patients with partially controlled asthma (25%) or well-
controlled asthma (12%) (P < 0.05 for all comparisons) (Table 2).
On multivariate regression analysis, the presence of insomnia (ISI ≥ 10) was signicantly associated with older age
(odds ratio [OR] = 1.02), obesity (OR = 3.32), absence of GERD symptoms (OR = 0.41), partially controlled asthma (OR
= 8.45), and uncontrolled asthma (OR = 3.59) (P < 0.05 for all factors) (Table 3).
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Table 1 Baseline Characteristics in Patients with Different Levels of Asthma Control
Characteristic All
(n=200)
Insomnia
(n=93)
No Insomnia
(n=107)
P value
Age (years) 51 ± 17 54 ± 16 47 ± 17 0.18
Female 135 (67) 68 (73) 67 (63) 0.11
Married 146 (73) 67 (72) 79 (74) 0.78
Educated
‡
176 (88) 80 (86) 96 (90) 0.42
BMI (kg/m
2
)* 31 (9.6) 32 (10) 29 (8.8) 0.50
Ever smoked 7 (3) 3 (3) 4 (4) 0.84
Coffee/tea intake 3.0 ± 3.0 / 2.0 ± 1.8 3.6 ± 3.6 / 2.0 ± 1.9 2.6 ± 2.7 / 1.8 ± 1.7 0.18/ 0.15
Sleep duration, hours* 6 (2) 5 (3) 6 (2) 0.01
Comorbid conditions
Allergic rhinitis 96 (48) 43 (46) 53 (50) 0.64
GERD 38 (19) 12 (13) 26 (24) 0.04
Diabetes mellitus 71 (35) 35 (38) 36 (34) 0.56
Hypertension 90 (45) 51 (55) 39 (36) 0.01
Asthma control test score 17 ± 4.9 15 ± 4.4 19 ± 4.5 0.001
FEV1, % predicted 76 ± 19.3 83 ± 23.2 77 ± 22.7 0.32
FVC, % predicted 82 ± 22.6 83 ± 22.7 82 ± 20.7 0.34
FEV1/FVC, % predicted 77 ± 15.7 79 ± 12.9 77 ± 15.6 0.45
ISI score 10 ± 7.2 16 ± 4.5 4±2.9 0.001
Notes: Data were expressed as mean ± standard deviation or as a number (percentage) unless otherwise specied. *Median (interquartile range).
‡
Educated: achieved more
than primary school.
Abbreviations: BMI, body mass index; GERD, gastroesophageal reux disease; ISI, Insomnia Severity Index.
Table 2 Insomnia Severity Index Comparisons According to Level of Asthma Control
Asthma Control
Well-Controlled
(n=67)
Partially Controlled
(n=55)
Uncontrolled
(n=78)
P value
Total ISI score, median (IQR) 2 (6) 9 (10) 12 (9) <0.001
Insomnia, ISI ≥10 13 (19%) 27 (49%) 53 (68%) <0.001
Insomnia severity
No insomnia (ISI = 0–7) 52 (78%) 23 (42%) 15 (19%) <0.001
Sub-threshold insomnia (ISI = 8–14) 7 (10%) 18 (33%) 30 (38%)
Moderate insomnia (ISI = 15–21) 7 (10%) 10 (18%) 24 (31%)
Severe insomnia (ISI = 22–28) 1 (2%) 4 (7%) 9 (12%)
Abbreviations: IQR, interquartile range; ISI, Insomnia Severity Index.
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Discussion
In this study, we determined the prevalence of insomnia among a sample of adults with asthma seen in specialized
pulmonary clinics at a tertiary care center in Saudi Arabia and examined the association between insomnia and level of
asthma control. We found a high prevalence of insomnia, with almost one-half of all patients reporting insomnia
symptoms (ISI ≥ 10). Moreover, asthma control was inversely related to insomnia; insomnia was more common in
patients with partially controlled or uncontrolled asthma than in those with well-controlled asthma.
The high prevalence of insomnia in our sample of asthmatic patients (46.5%) was consistent with the prevalence rates
of 22% to 47% reported in the literature.
19,20,23–28
In their study of 714 participants in the Severe Asthma Research
Program III, Luyster et al
19
found an insomnia prevalence rate of 37%. Among 470 asthmatic patients from Nordic
countries who participated in the European Community Respiratory Health Survey II, Sundberg et al
20
observed an
insomnia prevalence rate of 20% in men and 45% in women.
Our results also revealed that the prevalence and severity of insomnia differed across different levels of asthma control.
Insomnia was reported by 68% of the patients with uncontrolled asthma, 49% of the patients with partially controlled asthma,
and only 19% of those with well-controlled asthma. Moreover, moderate or severe insomnia was more frequent among
patients with uncontrolled or partially controlled asthma than in patients with well-controlled asthma. In the abovementioned
study by Luyster et al,
19
the presence of not well-controlled asthma (ACT score ≤19) was associated with a 2.4-times
increased risk of insomnia. Furthermore, not well-controlled asthma was reported by 78% of the patients with insomnia and
53% of those without insomnia.
19
Sundbom et al
20
also reported a higher prevalence of insomnia in patients with
uncontrolled asthma (32%) than in those with partially controlled asthma (20%) or controlled asthma (20%).
A bidirectional association is noted between asthma and chronic insomnia. A prospective study conducted by Brumpton
et al
31
which include 17 927 participants who are free from asthma at baseline; 686 were diagnosed with asthma during the
11-year follow-up. The study showed three times increase in the risk of incident asthma in patients with chronic insomnia.
31
The association between insomnia and absence of GERD was unexpected nding and a strong possibility exists that
the association is a chance nding due to small number of patients with GERD (n=38). Previous studies showed high
prevalence of GERD in patients with insomnia.
29,30
This study has some limitations that warrant consideration. First, it is a cross-sectional study, which precludes us from
making causal inferences regarding the association between insomnia and asthma control. Second, the study included
a relatively low number of participants, and these participants were recruited from subspecialty clinics at a tertiary center
Table 3 Factors Associated with the Presence of Insomnia
Odds Ratio 95% CI P value
Age (years) 1.02 1.00–1.05 0.04
Female 1.55 0.72–3.36 0.26
Married 0.70 0.33–1.50 0.37
Educated
‡
1.05 0.37–2.97 0.93
Ever smoked 1.61 0.27–9.55 0.60
Coffee/tea intake 0.57 0.17–1.95 0.37
BMI ≥30 kg/m
2
3.32 1.15–9.62 0.03
Allergic rhinitis 1.01 0.52–1.97 0.97
GERD 0.41 0.17–0.96 0.04
Partially controlled asthma 8.45 3.68–19.39 0.001
Uncontrolled asthma 3.59 1.49–8.64 0.004
Note:
‡
Educated: achieved more than primary school.
Abbreviations: BMI, body mass index; CI, condence interval; GERD, gastroesophageal reux disease.
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and were predominantly women. Thus, there is a possibility of selection bias, and our ndings may not be generalizable
to other settings with different resources. Third, the lack of a matched control group without asthma prevented us from
comparing the prevalence of insomnia between adults with and without asthma. Fourth, theit is a cross-sectional study
conducted over a short period. Both asthma and insomnia vary in their severities throughout the seasons, which
inuences asthma control and insomnia. It also needs to be taken into consideration as it can affect the prevalence of
insomnia and the severity of asthma. Lastly, objectives measurements of sleep disturbance, such as sleep studies for OSA
and sleep diaries, were not done.
Conclusions
Insomnia is common among patients with asthma, especially those with suboptimal asthma control. Further studies are
required to better understand the complex relationships between asthma and insomnia.
Data Sharing Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable
request.
Ethics Approval and Consent to Participate
The study was approved by the institutional review board of King Abdullah International Medical Research Center
(KAIMRC) in Riyadh, Saudi Arabia. All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments. Written informed consent was obtained from all participants.
Author Contributions
All authors made a signicant contribution to the work reported, whether that is in the conception, study design,
execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically
reviewing the article; gave nal approval of the version to be published; have agreed on the journal to which the article
has been submitted; and agree to be accountable for all aspects of the work.
Funding
This study received no funding.
Disclosure
The authors declare that they have no competing interests.
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