OSA Symptoms Associated With and Predictive of Anxiety in Middle-Aged Men: Secondary Analysis of NHANES Data April L. Shapiro a, ⁎, Stacey Culp b, 1 , Ilana R. Azulay Chertok c, 2 a School of Nursing, West Virginia University, 600 Harley O. Staggers Sr. Drive, Keyser, WV b School of Nursing, West Virginia University, 6404 Health Sciences South Morgantown, WV c School of Nursing, West Virginia University, 6504 Health Sciences South, Morgantown, WV abstract Object: This population-based study examined obstructive sleep apnea (OSA) symptoms predictive of anxiety in middle-aged men. Method: Secondary analyses were conducted on the National Health and Nutrition Examination Survey (NHANES) 2007–2008 data using weighted samples and complex sample analysis techniques (unweighted N = 1,217). Findings: Nonrefreshing sleep (χ 2 = 69.333, p b 0.001), excessive daytime sleepiness (χ 2 = 47.766, p b 0.001), and sleep fragmentation (χ 2 = 30.692, p b 0.001) were significantly associated with anxiety. Nonrefreshing sleep (OR 3.582, p b 0.001) and awakenings due to apneic episodes (OR 2.047, p = 0.001) were predictive of anxiety. Conclusion: Comorbid anxiety and OSA symptoms are common and have implications for activities of daily living, social responsibilities, and quality of life. Screening for anxiety among men with OSA symptoms is recommended. © 2014 Elsevier Inc. All rights reserved. Anxiety is a common mood associated with sleep difficulties, specifically obstructive sleep apnea (OSA) (DeZee, Hatzigeorgiou, Kristo, & Jackson, 2005; Ye, Liang, & Weaver, 2008). Strong associations between OSA or OSA symptoms and anxiety have been demonstrated in several studies (Macey, Woo, Kumar, Cross, & Harper, 2010; Sampaio, Pereira, & Winck, 2012; Sharafkhaneh, Giray, Richardson, Young, & Hirshkowitz, 2005; Yue et al., 2003), with a reciprocal impact of anxiety and sleep patterns noted (Andrews & Oei, 2004). However, the relationship between obstructive sleep apnea and anxiety is poorly understood (Kjelsberg, Ruud, & Stavem, 2005) and is commonly overlooked (Andrews & Oei, 2004). In those diagnosed with OSA, it is unclear whether anxiety and its associated psychopathological changes are related to the disease itself or to the OSA symptoms, such as sleepiness and sleep fragmentation (Sforza, de Saint Hilaire, Pelissolo, Rochat, & Ibanez, 2002). Anxiety among middle-aged men with OSA symptoms is under- studied. Attention to prevalence and predictors of anxiety among men with OSA is limited, despite reports that anxiety occurs in varying degrees within the male OSA population, spanning the continuum from mild to panic (Edlund, McNamara, & Millman, 1991). There are gaps in the literature related to the relationship between OSA symptoms and anxiety, the association between the symptoms and predicting anxiety, and the implications of these factors on quality of life, specifically among middle-aged men. Thus, further exploration of symptoms of sleep apnea as predictors of anxiety is warranted. The purpose of this study was to identify symptoms of OSA that are associated with and predictive of anxiety in middle-aged men. Anxiety is defined as an abnormal, overwhelming sense of apprehen- sion, worry, unease, and fear about something with an uncertain outcome or over an anticipated ill (Anxiety, 2012a,b). Anxiety, especially at severe and panic levels, can have major impacts on breathing and sleeping. In a sample of 49 newly diagnosed, untreated OSA patients without major comorbidities, higher anxiety scores correlated with higher sleep quality index scores (r = 0.47, p b 0.001), indicating poorer sleep outcomes (Macey et al., 2010). Within the OSA population, anxiety is a factor that may impact treatment acceptance and adherence (Aloia, Arnedt, Riggs, Hecht, & Borrelli, 2004). Treatment adherence among middle-aged men with OSA is poor (Aloia et al., 2004); consequently, low compliance with continuous positive airway pressure (CPAP) therapy has been associated with higher levels of anxiety (odds ratio [OR] = 5.60, 95% confidence interval [CI) 1.69, 18.58, p = 0.005) and has been shown to be a positive predictor of high anxiety scores (Kjelsberg et al., 2005). Anxiety has demonstrated to be the strongest predictor of health- related quality of life (β = 0.538, F = 21.198, p b 0.001), affecting daily functioning, social interactions, emotional functioning, and symptoms, in men with OSA (Ye et al., 2008). The etiology, impact on patients' daily lives, and relationship with anxiety varies by OSA symptom. Anxiety Archives of Psychiatric Nursing xxx (2014) xxx–xxx ⁎ Corresponding Author: April L. Shapiro, RN, MS, MS, PhD Student, School of Nursing, West Virginia University, 600 Harley O. Staggers Sr. Drive, Keyser, WV 26726. E-mail addresses: ashapiro@mix.wvu.edu (A.L. Shapiro), sculp@hsc.wvu.edu (S. Culp), ichertok@hsc.wvu.edu (I.R. Azulay Chertok). 1 Tel.: +1 304 293 6409. 2 Tel.: +1 304 293 6518. 0883-9417/1801-0005$34.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnu.2014.02.002 Contents lists available at ScienceDirect Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu Please cite this article as: Shapiro, A.L., et al., OSA Symptoms Associated With and Predictive of Anxiety in Middle-Aged Men: Secondary Analysis of NHANES Data, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.02.002