Sleep Problems in Primary Care: A North Carolina
Family Practice Research Network (NC-FP-RN) Study
Maha Alattar, MD, John J. Harrington, MD, MPH, C. Madeline Mitchell, MURP, and
Philip Sloane, MD, MPH
Methods: We approached 2963 consecutive adults who presented for office visits to the 5 study practices.
The 4-page study questionnaire, which was available in English and Spanish, included items on insomnia,
excessive daytime sleepiness, obstructive sleep apnea syndrome, and restless legs syndrome. Analyses evalu-
ated the relationship between sleep syndromes and demographic factors, health status, and disability.
Results: We enrolled 1935 patients (65.3% response rate). More than half reported excessive day-
time sleepiness, one third had insomnia, more than 25% had symptoms of restless legs syndrome, and
13% to 33% reported obstructive sleep apnea syndrome symptoms. Participants who rated their health
as poor reported significantly higher rates of all sleep disturbance items. Patients with hypertension,
pain syndromes, and depression had a significantly increased risk for all sleep complaints. Patients who
reported limited activity had a significant risk of restless legs syndrome.
Conclusion: Sleep complaints are highly prevalent in primary care populations. Patients with the
highest risk for sleep disturbance are those with pain, mental illness, limited activity, and overall “poor
physical and mental health.” Because sleep disorders are associated with a significant health impact,
positive responses to questions regarding sleep symptoms should prompt further diagnostic inquiry.
(J Am Board Fam Med 2007;20:365–374.)
Sleep is an essential restorative physiologic phe-
nomenon, and impaired sleep can have significant
negative impact on health. Sleep disorders have
been linked to impaired cognition, poor job per-
formance, motor vehicle accidents, and increased
health care use.1,2Sleep disorders are common in
adults, especially in the elderly3–5; they include in-
somnia, excessive daytime sleepiness (EDS), ob-
structive sleep apnea syndrome (OSAS), and rest-
less legs syndrome (RLS). Because of their impact
on quality of life, primary care physicians should be
aware of these common sleep disorders.
A considerable proportion of adults (43%) re-
port EDS that interferes with daily activities.6EDS
is generally caused by a sleep disorder or inade-
quate sleep; in clinical settings, it typically presents
as decreased stamina or daytime grogginess.7EDS
carries a risk of increased work-related or motor
vehicle accidents. Comorbid conditions, including
medical (eg, heart disease and arthritis); psychiatric
(eg, depression); and other sleep disorders (eg,
OSAS) are important risk factors for EDS. Sub-
stance abuse and sedating medications are contrib-
Insomnia is characterized by difficulty initiating
or maintaining sleep, often leading to EDS. Sleep
initiation insomnia is associated with depression or
anxiety, stress (“burnout”), or a primary sleep dis-
This article was externally peer reviewed.
Submitted 1 September 2006; revised 8 January 2007;
accepted 16 January 2007.
From the University of North Carolina, Chapel Hill (MA,
CMM, PS) and the National Jewish Medical and Research
Center, Denver, CO (JJH).
Funding: This research study was conducted in a practice-
based research network consisting of a representative sample
of family practices in North Carolina, from which a cohort
of patients has been enrolled and is maintained longitudi-
nally. The network is called the North Carolina Family
Practice Research Network (NC-FP-RN), and the cohort is
called the North Carolina Health Project (NCHP) cohort.
The NC-FP-RN and the NCHP are jointly sponsored by
the Department of Family Medicine, the Thurston Arthritis
Research Center, and the Cecil G. Sheps Center for Health
Services Research at the University of North Carolina at
Chapel Hill (UNC-CH), in collaboration with the North
Carolina Academy of Family Physicians. Activities of the
NC-FP-RN and NCHP have been supported by the Cen-
ters for Disease Control and Prevention, the Agency for
HealthCare Research and Quality, the National Institutes of
Health, the Department of Family Medicine at UNC-CH,
and the Program on Health Outcomes at UNC-CH.
Conflict of interest: none declared.
Corresponding author: Maha Alattar, MD, University of
North Carolina, Neurology-Sleep and Epilepsy Section,
3114 Bioinformatics Building, Chapel Hill, NC 27599-0001
doi: 10.3122/jabfm.2007.04.060153Sleep Problems in Primary Care 365
order such as RLS. Frequent nighttime awakenings
reflect disruption in normal sleep mechanisms and
are often caused by medical disorders such as ar-
thritis or primary sleep disorders such as OSAS.
Drug or alcohol abuse, caffeine, or shift work can
contribute to insomnia.
OSAS is common in the general population.
Snoring, gasping for air, or difficulty breathing at
night, coupled with EDS and frequent awakenings,
are cardinal signs of OSAS. Risk factors include
obesity, crowded oropharyngeal airway, older age,
male sex, hypertension, and cardiovascular dis-
ease.8–10Because many of these risk factors are
more common among primary care patients than in
the general population, it is likely that people with
OSAS present frequently in primary care settings.11
OSAS leads to an increased risk of vascular disease,
such as hypertension. Therefore, recognition and
treatment of OSAS is clinically important.
The reported prevalence of RLS in the general
population ranges from 2.5% to 15%, with in-
creased prevalence among the elderly. RLS is un-
pleasant and typically occurs during rest (in the
evening or bedtime), with relief provided by rub-
bing the legs or walking. Patients with RLS have
difficulty falling asleep and frequently experience
EDS. RLS is also associated with poor general
health, depression, end-stage renal disease, preg-
nancy, iron deficiency, peripheral neuropathies,
medications (eg, tricyclic antidepressants or selec-
tive serotonin reuptake inhibitors), caffeine, and
The prevalence and nature of sleep disorders in
the primary care population has not been widely
studied. Therefore, as part of a survey conducted in
5 family practice offices, we screened adult patients
for sleep syndromes and sought to ascertain which
demographic and health status factors were associ-
ated with the presence of these disorders.
Data Collection Sites and Study Subjects
This research study was conducted in a practice-
based research network consisting of a representa-
tive sample of family practices in North Carolina,
the North Carolina Family Practice Research Net-
work (NC-FP-RN). Subjects were recruited from 5
primary care sites in North Carolina. Two were
rural community health centers, 2 were suburban
private practices, and 1 was a university-affiliated
practice located in a small town. In each study
practice, patient enrollment and data collection
were conducted for 1 month. This length of time
was chosen to maximize the number of subjects
enrolled yet minimizing the number of repeat pa-
During data collection, all patients 18 years of
age and older who had an appointment with a
physician, physician assistant, or nurse practitioner
were eligible to enroll. Eligible subjects were ap-
proached before their appointment, and informed
consent was solicited using procedures approved by
the Committee for the Protection of the Rights of
Human Subjects of the University of North Caro-
lina School of Medicine. Consenting subjects could
either complete the questionnaire on their own or,
if desired, be interviewed by a data collector. Fam-
ily members who accompanied subjects were per-
mitted to provide assistance. Patients who were
acutely ill or did not feel like completing the survey
in the waiting room but still wanted to participate
were given the survey and a return address enve-
Measures and Data Collection
The data collection instrument was a 4-page self-
report health questionnaire, which was available in
both English and Spanish and required 10 to 15
minutes to complete. It included (1) the following
demographic and health status items: birth date,
height and weight (from which body mass index
was calculated), sex, race/ethnicity, smoking status,
self-reported health, years of education, and marital
status14,15; (2) questions about the presence or ab-
sence of heart disease, high blood pressure, lung
disease, stroke (or “mini-stroke”), depression, back
pain, joint pain, arthritis (including gout, lupus, and
fibromyalgia), cancer, and diabetes; (3) self-report
items on days of disability because of physical or
mental health problems16; and (4) a series of items
on sleep-related symptoms, which were modified
from existing instruments.17,18
The study’s data collection questions about sleep
disorders are included as Appendix A. Respondents
were screened for EDS with 2 questions: one re-
garding subjective sleepiness and one regarding
dozing off during daytime activities. A question
about tingling, creeping, or restless feelings in the
legs while trying to sleep was used to screen for
RLS. The questionnaire screened for sleep-related
breathing disorders and, in particular, OSAS with 2
July–August 2007Vol. 20 No. 4 http://www.jabfm.org
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35. Nichols DA, Allen RP, Grauke JH, et al. Restless
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36. Allen RP, Walters AS, Montplaisir J, et al. Restless legs
syndrome prevalence and impact: REST general pop-
ulation study. Arch Intern Med 2005;165:1286–92.
37. Tison F, Crochard A, Leger D, Bouee S, Lainey E,
El Hasnaoui A. Epidemiology of restless legs syn-
drome in French adults: a nationwide survey: the
INSTANT Study. Neurology 2005;65:239–46.
38. Garvey MJ, Tollefson GD. Occurrence of myoclo-
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Arch Gen Psychiatry 1987;44:269–72.
39. Bakshi R. Fluoxetine and restless legs syndrome.
J Neurol Sci 1996;142:151–2.
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