Statement of Principles
concerning
 
SLEEP APNOEA
No. 41 of 2013
 
for the purposes of the
 
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
Title
1.         This Instrument may be cited as Statement of Principles concerning sleep apnoea No. 41 of 2013.
Determination
2.         The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a)        revokes Instrument No. 13 of 2005 concerning sleep apnoea; and
(b)        determines in its place this Statement of Principles.
Kind of injury, disease or death
3.         (a)        This Statement of Principles is about sleep apnoea and death from sleep apnoea.
(b)               For the purposes of this Statement of Principles, "sleep apnoea" means sleep-disordered breathing characterised by periods of cessation or reduction in airflow at the nose and mouth, with at least five apnoea or hypopnoea episodes per hour of sleep, and leading to arousals from sleep and disrupted sleep architecture, together with significant clinical consequences such as excessive daytime sleepiness, impaired memory, difficulty concentrating, morning headache, pulmonary hypertension, right heart failure or respiratory failure.  This definition includes obstructive sleep apnoea, central sleep apnoea and mixed sleep apnoea.
(c)                Sleep apnoea attracts ICD-10-AM code G47.30, G47.31, G47.32, G47.33 or G47.39.
(d)               In the application of this Statement of Principles, the definition of "sleep apnoea" is that given at paragraph 3(b) above.
Basis for determining the factors
4.         The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that sleep apnoea and death from sleep apnoea can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
Factors that must be related to service
5.         Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
Factors
6.         The factor that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting sleep apnoea or death from sleep apnoea with the circumstances of a person’s relevant service is:
(a)                for obstructive sleep apnoea only,
(i)                 having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical onset of sleep apnoea; or
(ii)               being obese at the time of the clinical onset of sleep apnoea; or
(iii)             having hypothyroidism at the time of the clinical onset of sleep apnoea; or
(iv)             having acromegaly at the time of the clinical onset of sleep apnoea; or
(v)               being treated with antiretroviral therapy for human immunodeficiency virus infection before the clinical onset of sleep apnoea; or
(b)               for central sleep apnoea only,
(i)                 having congestive cardiac failure at the time of the clinical onset of sleep apnoea; or
(ii)               using a long-acting opioid at an average daily morphine equivalent dose of at least 75 milligrams for at least the two months before the clinical onset of sleep apnoea; or
(c)                having a central nervous system lesion or disorder involving the upper or mid-cervical cord, brain stem, cerebrum or extrapyramidal system at the time of the clinical onset of sleep apnoea; or
(d)               having autonomic neuropathy at the time of the clinical onset of sleep apnoea; or
(e)                having chronic renal disease requiring renal transplantation or dialysis at the time of the clinical onset of sleep apnoea; or
(f)                having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical onset of sleep apnoea; or
(g)               being treated daily with an atypical antipsychotic drug, for a condition for which the drug cannot be ceased or substituted, for at least the two months before the clinical onset of sleep apnoea; or
(h)               for obstructive sleep apnoea only,
(i)                 having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical worsening of sleep apnoea; or
(ii)               being obese at the time of the clinical worsening of sleep apnoea; or
(iii)             having hypothyroidism at the time of the clinical worsening of sleep apnoea; or
(iv)             having acromegaly at the time of the clinical worsening of sleep apnoea; or
(v)               being treated with antiretroviral therapy for human immunodeficiency virus infection before the clinical worsening of sleep apnoea; or
(i)                 for central sleep apnoea only,
(i)                 having congestive cardiac failure at the time of the clinical worsening of sleep apnoea; or
(ii)               using a long-acting opioid at an average daily morphine equivalent dose of at least 75 milligrams for at least the two months before the clinical worsening of sleep apnoea; or
(j)                 having a central nervous system lesion or disorder involving the upper or mid-cervical cord, brain stem, cerebrum or extrapyramidal system at the time of the clinical worsening of sleep apnoea; or
(k)               having autonomic neuropathy at the time of the clinical worsening of sleep apnoea; or
(l)                 having chronic renal disease requiring renal transplantation or dialysis at the time of the clinical worsening of sleep apnoea; or
(m)             having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical worsening of sleep apnoea; or
(n)               being treated daily with an atypical antipsychotic drug, for a condition for which the drug cannot be ceased or substituted, for at least the two months before the clinical worsening of sleep apnoea; or
(o)               consuming an average of at least 30 grams of alcohol per day for at least the six months before the clinical worsening of sleep apnoea; or
(p)               inability to obtain appropriate clinical management for sleep apnoea.
Factors that apply only to material contribution or aggravation
7.         Paragraphs 6(h) to 6(p) apply only to material contribution to, or aggravation of, sleep apnoea where the person’s sleep apnoea was suffered or contracted before or during (but not arising out of) the person’s relevant service.
Inclusion of Statements of Principles
8.         In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
Other definitions
9.         For the purposes of this Statement of Principles:
"a central nervous system lesion or disorder" means a condition such as a tumour or trauma-induced lesion, cerebrovascular accident, Parkinson’s disease, multiple sclerosis or Alzheimer-type dementia;
"a long-acting opioid" means an opioid drug with a duration of action of at least three hours, and used to treat chronic pain or narcotic addiction;
"a neuromuscular disease" means a condition such as muscular dystrophy, myasthenia gravis or Charcot-Marie-tooth disease;
"acromegaly" means a chronic disease of adults resulting from hypersecretion of growth hormone after closure of the epiphyses;
"alcohol" is measured by the alcohol consumption calculations utilising the Australian Standard of ten grams of alcohol per standard alcoholic drink;
"autonomic neuropathy" means any neuropathy of the autonomic nervous system, affecting mostly the internal organs such as the bladder, the cardiovascular system, the digestive tract and the genital organs.  It is a complication of many diseases including Adie’s syndrome, chronic alcoholism, diabetes mellitus, dysautonomia and Shy-Drager syndrome;
"being obese" means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of 30 or greater.
The BMI = W/H2 and where:
W is the person’s weight in kilograms; and
H is the person’s height in metres;
"central sleep apnoea" means a type of sleep apnoea characterized on sleep study by repetitive cessation or decrease of both airflow and respiratory effort during sleep;
"congestive cardiac failure" means a clinical syndrome due to heart disease, resulting in congestion in the peripheral circulation with or without congestion of the lungs;
"death from sleep apnoea" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s sleep apnoea;
"ICD-10-AM code" means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Eighth Edition, effective date of 1 July 2013, copyrighted by the Independent Hospital Pricing Authority, and having ISBN 978-1-74128-213-9;
"obstructive sleep apnoea" means a type of sleep apnoea characterized on sleep study by repetitive cessation or decrease of airflow in the presence of respiratory effort during sleep;
"relevant service" means:
(a)                operational service under the VEA;
(b)                peacekeeping service under the VEA;
(c)                hazardous service under the VEA;
(d)               British nuclear test defence service under the VEA;
(e)                warlike service under the MRCA; or
(f)                 non-warlike service under the MRCA;
"terminal event" means the proximate or ultimate cause of death and includes:
(a)                pneumonia;
(b)               respiratory failure;
(c)                cardiac arrest;
(d)               circulatory failure; or
(e)                cessation of brain function;
"the upper airway" means the nasal cavity, nasopharynx, oropharynx, hypopharynx or larynx.
Application
10.       This Instrument applies to all matters to which section 120A of the VEA or section 338 of the MRCA applies.
Date of effect
11.       This Instrument takes effect from 3 July 2013.
Dated this   twenty-first   day of   June   2013
The Common Seal of the                    )
Repatriation Medical Authority          )
was affixed to this instrument                        )
in the presence of:                               )
PROFESSOR NICHOLAS SAUNDERS AO
CHAIRPERSON