Table 3.

Key similarities, differences, and contextual factors to consider when evaluating military sleep medicine patients.

Factors for Consideration	Civilian Patients	Military Patients
Disease prevalence, Narcolepsy	0.014–0.07% may be at risk for narcolepsy type I with cataplexy23,34 0.065–0.2% may be at risk for narcolepsy type II without cataplexy23,34	Unknown; might mirror civilian estimates but chronic sleep insufficiency, circadian misalignment, erratic shift work schedules, and psychiatric conditions confound such estimates
Disease prevalence, Idiopathic Hypersomnia	0.03% may be at risk24,25	Unknown; might mirror civilian estimates but chronic sleep insufficiency, circadian misalignment, shift work, and psychiatric conditions confound such estimates
Disease prevalence, OSA	Middle aged adults are at risk for OSA (based on an AHI of 5 events/h or greater)20,21 - 10–15% females - 15–30% males	9–12% across the Department of Defense.51–52 Some studies reporting 65% at risk among those screened with PSG; but rates are variable and pretest probability using standard metrics such as STOP-BANG and ESS are less useful due to chronic insufficient sleep and disability incentive3,7
Insufficient sleep
< 6 h/night habitually	29%11	62.7–72%3,7,8
< 5 h/night habitually	8%11	31.4–43%3,7,8
Occupational culture surrounding sleep	Variable; many professions that endorse a culture of productivity at expense of sleep include: - Healthcare (Physicians in-training, Nurses) - Emergency response services - Food service and Hospitality industry - Law enforcement	Long standing traditions surrounding extended workdays and early start times (earlier than 6 A.M.) for unit physical fitness. Many service members have long commute times to work, especially in urban areas where military income does not match housing costs close to work.
Shift Work	Variable; although many professions have established patterns of shift work, engagement in these occupations varies: - Healthcare - Commercial transportation - Fire fighters - Law enforcement	Extensive and sometimes hidden shift work schedules. Field training and deployment operations requiring 24/7 manning. Many leadership rolls encompass 24/7 responsibility by phone. Senior leaders may have several separate leadership jobs due to personnel shortages. Early work start times that are outside a normal 9 A.M.-5 P.M. schedule in addition to evening meetings, night-work and weekends.
Disability, OSA	No specific disability rating. Potential disincentives (ie, driving license restrictions in some states)	There is a Veterans Affairs disability rating for the diagnosis of OSA - 30% disability rating if you have OSA coupled with excessive daytime sleepiness - 50% disability rating if you have OSA that is treated with CPAP (this may equate to up to $1,000 per month for life) - 100% disability rating if you have OSA with hypercapnic respiratory failure that requires long term noninvasive ventilation or tracheostomy/invasive mechanical ventilation (this may equate to up to $3,400 per month for life)
Disability, Narcolepsy	No specific disability rating. Potential disincentives (ie, driving license restrictions in some states)	There is a Veterans Affairs disability rating for the diagnosis of Narcolepsy: - 80% disability rating
Implications for Future Employment	A diagnosis of narcolepsy or OSA does not impact your occupational capability for many jobs.	A diagnosis of narcolepsy or OSA can render a Service member limited in the following ways, depending on final diagnosis and response to treatment: - Not suitable for retention in the military - Medical retirement - Administrative separation - Nondeployable to overseas assignments - Not eligible for certain occupations (special operations, aviation)
Take Home Points	- Most patients pursue evaluation because they are experiencing distressing symptoms of daytime sleepiness or snoring that disrupts a bed partner - Patients place value on the benefit of CPAP improving symptoms, or they abandon therapy - Patients generally prefer to not have to use CPAP, hence the rising popularity of surgical treatments such as hypoglossal nerve stimulation and medications being evaluated for the treatment of OSA) - A diagnosis of OSA may be perceived negatively due to a requirement for equipment, change in bedtime routine, stigma, cost - The diagnoses of OSA and Narcolepsy may lead to restrictions on driving a personal vehicle in addition to commercial driving or occupational constraints - No financial incentive from a disability standpoint to have these conditions - Cost of medical care may be high	- Military service members are generally younger, thinner, and have fewer medical problems by virtue of the screening protocols and routine mandatory health examinations that guide accession into the services and retention in the military - Theoretically, lower pretest probability for sleep disorders due to above accession and retention requirements - Significant financial disability rating incentive (may equate to more than 1000$ per month for life in addition to medical coverage and additional benefits) - No cost for medical care (ie, no cost for evaluation or treatment of narcolepsy; no cost for CPAP therapy or sleep studies)

AHI = apnea-hypopnea index, CPAP = continuous positive airway pressure, ESS = Epworth Sleepiness Scale, PSG = polysomnography.