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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.75 no.11 São Paulo Nov. 2017 


The critical influence of nocturnal breathing complaints on the quality of sleep after stroke: the Pittsburgh Sleep Quality Index and STOP-BANG

A influência crítica das queixas respiratórias noturnas na qualidade final do sono após acidente vascular cerebral: índice de qualidade de sono de Pittsburgh e STOP-BANG

Giuliano da Paz Oliveira1 

Eliana Regina Lottemberg Vago1  2 

Gilmar Fernandes do Prado1 

Fernando Morgadinho Santos Coelho1  2 

1Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil

2Universidade Federal de São Paulo, Departamento de Psicobiologia, São Paulo SP, Brasil


In stroke patients particularly, many factors, such as sleep-related respiratory disturbances, can impair sleep. Cheap and easy-to-use tools have been created to identify sleep quality and sleep disturbances in patients after stroke. This study described the scores of the sleep apnea screening questionnaire - STOP-BANG - in patients after a stroke, and correlated the findings with sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). The scores of the STOP-BANG and PSQI were 4.3 ± 1.8 and 76 ± 3.9, respectively. The STOP-BANG scores were higher in poor sleepers (4.5 ± 1.6 versus 3.5 ± 1.9; p = 0.032). Logistic regression analysis was used to identify predictors of subjective sleep quality (PSQI) and the STOP-BANG as a predictor of poor quality sleep, with a relative risk of 1.6, controlled for age and sex. This study indicated that sleep quality was largely influenced by sleep breathing problems, which were well identified by the STOP-BANG, especially in younger stroke patients.

Keywords: stroke; sleep; surveys and questionnaires


Especialmente em pacientes com acidente vascular cerebral (AVC), muitos fatores prejudicam o sono, como distúrbios respiratórios do sono (DRS). Ferramentas mais baratas foram usadas para identificar a qualidade do sono e distúrbios do sono após AVC. Este estudo verificou a influência das queixas DRS na qualidade do sono após AVC utilizando questionários. Nós investigamos a qualidade do sono eo risco de Apneia Obstrutiva do Sono com o Índice de Qualidade do Sono de Pittsburgh (PSQI) e Stop-Bang em 68 pacientes após AVC. As pontuações de STOP-BANG e PSQI foram de 4,3 ± 1,8 e 7,6 ± 3,9, respectivamente. As pontuações de STOP-BANG foram mais elevadas em pacientes com sono ruim (4,5 ± 1,6 versus 3,5 ± 1,9; p = 0,032). A regressão logística caracterizou o STOP-BANG como preditor de um sono de má qualidade. Estes achados confirmam a influência das queixas respiratórias noturnas na qualidade do sono após AVC.

Palavras-chave: acidente vascular cerebral; sono; inquéritos e questionários

Sleep quality influences health and poor quality of sleep can worsen clinical conditions and impair treatment and rehabilitation in stroke patients1,2,3. The impact of poor sleep quality in prevalent diseases such as stroke is enormous4,5,6.

Sleep-related respiratory disturbances after stroke are very common (40-80%)7. They frequently worsen neurologic recovery and impair quality of life8,9. Sleep-related respiratory disturbances are independent risk factors for new strokes, as well as other cardiovascular events. The main sleep-related respiratory disturbance is obstructive sleep apnea, which is characterized by repeated interruption of ventilation during sleep due to pharyngeal airway closure with consequent sleep fragmentation and intermittent hypoxia. Obstructive sleep apnea is correlated with hypertension, diabetes, obesity, stroke, heart attack and a higher incidence of death4,10,11. The prevalence of obstructive sleep apnea is three-to-four times higher in patients after a stroke12.

The high cost and prevalence of stroke associated with a greater frequency of sleep disorders justify efforts to determine the best option to identify this overlap. The diagnosis and treatment of sleep disorders is a field that has expanded considerably over recent years.

Unfortunately, the traditional investigation of sleep disturbance is expensive and complicated. This makes it impossible to perform sleep studies for the major portion of stroke patients, in almost all parts of world. However, the physical and cognitive impairment of stroke patients with sleep disorders always needs to be considered in the clinical approach2,13. Thus, cheaper and easier-to-use tools have been created to identify sleep quality and sleep disturbances in patients after stroke - namely, the Pittsburgh Sleep Quality Index (PSQI) and the sleep apnea screening questionnaire - STOP-BANG14,15.

The PSQI is the most complete questionnaire for determining sleep quality, with seven components: subjective sleep quality, latency, duration, efficiency, sleep disorders, use of sleep medication and daytime dysfunction. Part of the PSQI covers sleep-related respiratory disturbances; however, it is frequently not used in clinical practice due its length. For an exclusively sleep-related respiratory disturbance investigation, the STOP-BANG can be used. This questionnaire is easier to use in clinical practice15,16.

The aim of this study was to describe the scores of the STOP-BANG questionnaire in patients after stroke and correlate the findings with sleep quality measured by the PSQI.


Sample and ethics

Seventy-five patients who had had a stroke (ischemic and hemorrhagic) within the last year, over 18 years of age, who attended the Neurovascular Clinic of the Universidade Federal de São Paulo (UNIFESP) consecutively, between March and June 2016, were invited to participate. This study was reviewed and approved by the Institutional Research Ethics Committee of UNIFESP (CAAE: 55362516.6.0000.5505).

The study exclusion criteria were: 1) patients younger than 18 years old; 2) uncontrolled psychiatric illness; 3) confusion or severe cognitive impairment; 4) aphasia; 5) use of sedative or hypnotic medications and 6) more than one year after stroke event. Seven patients were excluded: five patients due to aphasia and two patients due to dementia. Informed consent was obtained from all 68 patients studied.

Study design

This was a cross-sectional, observational study, in a single center - the Department of Neurology, Neurovascular Clinic of UNIFESP. Every assessment was made by filling out forms and questionnaires with the patient.

Demographic characteristics (age and gender), anthropometric features (weight, height, body mass index (BMI), and a measurement of neck circumference, and clinical characteristics (smoking status, diagnosis of systemic arterial hypertension, diabetes mellitus and restless legs syndrome) were obtained. Systemic arterial hypertension was defined as a systolic blood pressure of 140 mm/Hg or higher or a diastolic blood pressure of 90 mm/Hg or higher, or regular use of antihypertensive medication. Diabetes mellitus was defined as a fasting blood glucose concentration of 126 mg/dl or higher or current use of antidiabetic medication. Restless legs syndrome was defined based on International Restless Legs Syndrome Study Group consensus criteria17.

The clinical characteristics of stroke; neurological impairment score on the National Institutes of Health Stroke Scale (NIHSS); etiologic classification according Trial of Org 10172 in Acute Stroke Treatment (TOAST), validated in Brazil; and evaluation of the degree of disability according to the modified Rankin Scale (mRS) were noted18,19,20.

All patients answered the PSQI and STOP-BANG questionnaires, validated in Brazil14,15,21,22,23,24.

Statistical analysis

Data analysis was performed using the SPSS 15.0 (Statistical Package for Social Science Software), considering a significance level of less than 5% for all statistical tests.

Data were expressed as mean and standard deviation: age, BMI, NIHSS, mRS, STOP-BANG, and PSQI. We determined the prevalence of arterial hypertension, diabetes mellitus, current smoking, restless legs syndrome, complaint of pain and poor quality of sleep in this population. The prevalence of ischemic and hemorrhagic strokes, as well as the classification of ischemic strokes was made according the TOAST criteria.

The Mann-Whitney test was used to compare good sleepers (PSQI < 5) and poor sleepers (PSQI > 5). Logistic regression analysis was applied considering the STOP-BANG score as an independent variable and sleep quality measured by the PSQI as the dependent variable, controlled for age and sex.


The mean age was 59.8 ± 12.9 years, 51.5% were male, the BMI was 26.5 ± 5.1 kg/m2, with the interview done within 163 ± 141 days after stroke. We observed a low average NIHSS score (2.8 ± 2.1) and degree of disability as measured by the mRS (1.5 ± 1.1). The prevalence of hypertension, diabetes mellitus and smoking were 83.8%, 35.3% and 22.1%, respectively. Of the 68 patients, 50 (73.5%) complained of pain, only nine (13.2%) filled the diagnostic criteria for restless legs syndrome, and 48 (70.6%) had poor sleep quality (Table 1).

Table 1 Demographic data and characteristics. 

Parameter Sample (n = 68)
Age (years) 59.8 ± 12.9
Male 35 (51.5%)
Body-mass index (kg/m2) 26.5 ± 5.1
Hypertension* 57 (83.8%)
Diabetes** 24 (35.3%)
Current smoker 15 (22.1%)
Restless legs syndrome 9 (13.2%)
Pain complaint 50 (73.5%)
NIHSS 2.8 ± 2.1
Mrs 1.5 (1.1)
STOP-BANG 4.3 ± 1.8
STOP-BANG ≥ 3 57 (83.8%)
PSQI 76 ± 3.9
Bad sleepers (PSQI ≥ 6) 48 (70.6%)

Data are mean (SD) or n (%).

*Defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher, or current use of antihypertensive medication;

**Defined as a fasting blood glucose concentration of 126 mg/dl or higher or current use of antidiabetic medication; NIHSS:National Institutes of Health Stroke Scale; mRS: Modified Rankin Scale; PSQI: Pittsburgh Sleep Quality Index.

Sixty-four (94.1%) patients had ischemic stroke and four (5.9%) had hemorrhagic stroke. The TOAST etiology classified the strokes as occlusion of small vessels (32.8%), inconclusive (26.6%), large artery atherosclerosis (18.8%), cardio- embolic (15.6%), and other causes (6.3%).

The STOP-BANG and PSQI scores were 4.3 ± 1.8 and 7.6 ± 3.9, respectively. Good sleepers (PSQI ≤ 5) were compared with poor sleepers (PSQI > 5). No significant differences were seen between good or poor sleepers for sex, presence of hypertension, diabetes mellitus, smoking, restless legs syndrome or the etiologic classification of stroke by TOAST. The STOP-BANG scores were higher in poor sleepers than good sleepers (4.5 ± 1.6 versus 3.5 ± 1.9; p = 0.032).

Logistic regression analysis was used to identify predictors of subjective sleep quality (PSQI score) making the STOP-BANG a predictor of a poor-quality sleep, at p < 0.05 and relative risk of 1.6, controlled for age and sex (Table 2).

Table 2 Logistic regression analysis considering the STOP-BANG scores as an independent variable and sleep quality measured by the Pittsburgh Sleep Quality Index as the dependent variable, controlled for age and sex. 

Variables Beta coefficient RR 95%CI p
STOP-BANG (each score) 0.478 1.61 1.03-2.51 0.035
Age (each year) -0.023 0.98 0.93-1.02 0.340
Male sex 0.821 2.27 0.50-10.20 0.284


We found that the STOP-BANG score worked as a predictor of a poor quality of sleep with a relative risk of 1.6, reflecting the impact of nighttime breathing problems on the sleep quality of post-stroke patients.

Quality of sleep is an important issue in stroke patients. Complaints of insomnia and increased sleep latency have been identified as predictors of a poor quality of sleep in patients after stroke2. Interestingly, self-reported questionnaires were better as predictors of sleep quality than sleep studies in patients with obstructive sleep apnea25.

The identification and treatment of predictors of poor sleep quality after stroke is very important, due to the potential impact on the patient's quality of life. According to the PSQI, 70.6% of our patients were considered poor sleepers (7.6 ± 3.9 points).

On the other hand, the sensitivity of the STOP-BANG questionnaire (three or more affirmative answers) for obstructive sleep apnea detection was 83.6%. This confirms that our patients had a higher risk of nocturnal breathing complaints after stroke. In fact, the higher scores of the STOP-BANG in poor sleepers (4.5 ± 1.6) compared with good sleepers (3.5 ± 1.9) indicate the large influence of nocturnal breathing problems on the quality of sleep after stroke in our cohort.

In contrast to the PSQI, the STOP-BANG is a practical tool: it is short, has an easy-to-remember mnemonic and a simple calculable scoring system. Furthermore, patients have relatively little difficulty in answering it, giving a high overall response rate26. The identification of impaired sleep quality and frequency of sleep disturbances in patients with stroke can lead to corrective measures, such as the establishment of proper routines and habits, as well as more appropriate time for therapeutic interventions27,28.

We are unaware of previous studies addressing the impact of nighttime respiratory problems measured by the STOP-BANG questionnaire in the sleep quality of patients after stroke. However, a few limitations must be highlighted. The characteristics of sleep analyzed were determined exclusively by self-reported data, without confirmation through complementary tests. In addition, we included both ischemic and hemorrhagic stroke patients, although they have different pathophysiological mechanisms29.

This study indicates that sleep quality was greatly influenced by sleep-related breathing problems, which were well identified by the STOP-BANG questionnaire, especially in younger stroke patients.


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Received: March 28, 2017; Revised: June 16, 2017; Accepted: August 08, 2017

Correspondence: Fernando Morgadinho Santos Coelho; Departamento de Neurologia e Neurocirurgia da UNIFESP; Rua Napoleão de Barros, 925 / 2° andar; 04024-002 São Paulo SP, Brasil; E-mail:

Conflict of interest: There is no conflict of interest to declare.

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