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Sleepless in America

May 2008
Sleepless in America

Do you wake up tired, feeling that you haven’t slept all night, even though you did sleep at a decent hour? Do you doze off during the day, at work or while watching television? Do you have headaches, fatigue, mood swings and irritability? Most important, do you have an annoyed spouse or significant other whom you’ve kept up all night because of your snoring? If you answered ‘yes’ to most of these questions, chances are you could have a serious disorder called ‘sleep apnea’ (SA).

Sleep apnea affects a large percentage of the population—but the problem is that most people with it have no complaints, or at least they don’t think their complaints constitute a real health problem and so don’t talk to the doctor about it. But it is serious! In fact, if left untreated, sleep apnea can cause not just marital discord, but also poor performance at work or school, sudden death in a car crash, and even an increased risk of developing hypertension, stroke, irregular heart beats, heart failure, heart attacks and diabetes. The last three decades have brought increasing understanding of sleep, and the study has evolved into a medical subspecialty.

What is Sleep Apnea?

People with sleep apnea stop breathing for up to 20 seconds during sleep, or have very shallow breathing. A smaller than normal amount of air flows through the airways to the lungs, leading to a decrease of oxygen in the blood. The brain interprets this as an emergency and responds by awakening the person just enough to open the windpipe. Normal breathing is resumed, often abruptly, and the person sleeps again. This process may occur up to 30 times each hour. Many people do this for years.

Sometimes this sleep apnea is caused by an instability of the respiratory control center, which causes the brain to fail to signal the muscles to breathe. About six million Americans have this central sleep apnea (CSA). About double that number, twelve million Americans, have obstructive sleep apnea (OSA) caused by collapsing of the soft tissue in the back of the throat, and blockage of the airway.

When air is being forced into a partially closed upper airway, airway structures vibrate, and the resulting sound is snoring. Snoring can seriously disrupt the sleep of the bed partner, who can become sleep deprived, depressed and prone to marital strife. Bed partners often describe how the person snores loudly, falls silent for what seems like eternity, and then resumes breathing, sometimes with a loud snort and sometimes actually waking up. The silent period is the obstructive sleep apnea (meaning, cessation or absence of breathing).

What are the signs and symptoms of OSA?

Most people with sleep apnea are unaware of this series of ‘emergencies’ during the night, and have no complaints. They say they sleep perfectly well. Something is wrong with their wives, who force them to see a doctor! It may be only when the spouse realizes that all that stopping breathing can’t be good, that they finally see a doctor!

Neither snorer nor spouse may recognize the severity of the problem for a long time. “My spouse (or I) can sleep any time, anywhere.” This is a common phrase heard not only in sleep clinics but also in social gatherings. Patients often do not realize that it is not normal to sleep any time and anywhere; rather this could be an indicator of SA, and other problems could be building.

Other patients may recognize that they have a sleep problem. They may wake feeling unrefreshed and sometimes have a headache. They long for more sleep and often remain tired and sleepy during the day, especially by mid morning or afternoon.

Many people have complaints but may not connect them with sleep. They complain of being less productive at work, forgetful and irritable, with mood swings. Men can also complain of erectile dysfunction or impotence. Many people are diagnosed with depression. Some people drink several cups of coffee, tea or caffeinated sodas and may deny sleepiness but are still sleep deprived.

What are the clinical consequences of OSA?

· OSA has been shown to be associated with hypertension or high blood pressure, which improves or resolves when OSA is treated.

· Several kinds of irregular heart beat can occur in patients due to OSA: among patients with atrial fibrillation, for example, those with OSA are much harder to treat until the OSA itself is treated.

· Atherosclerosis means hardening of the arteries and is an important precursor condition to heart attack and strokes. Inflammation of the lining of blood vessels is a key component of atherosclerosis. OSA is being implicated in this process. So in addition to being in an indirect risk factor (by causing hypertension), now it is being thought of as a direct risk factor for diseases like heart attacks and strokes.

· Similarly glucose control has been shown to be affected by OSA and again improve with treatment of OSA. A recent 5-year study suggests that patients with OSA have a 2.7-fold risk of developing diabetes. "I often say that we should include sleep apnea as one of the components of the metabolic syndrome," says Dr. Safwan M. Badr of Michigan. He further recommends screening diabetic patients for sleep apnea in case treatment might reduce the risk of diabetic complications.

· Before these diseases strike, the noticeable effects may be disruption of sleep (for both partners), waking up tired, and feeling tired and sleepy all day long. SA can also result in memory deficits and feeling depressed. It may be responsible for poor performance at work, motor vehicle crashes, and—don’t laugh if your child snores!—academic underachievement in children and adolescents.

Who is at risk for OSA?

SA can affect men, women and children, although it is more common in older adults and more common in men than women. Postmenopausal women are at increased risk for OSA, presumably due to hormonal changes. Enlarged tonsils and narrowed airways may become a problem. Smokers are much more likely to have OSA because of inflammation and fluid retention in the upper airway. Obesity is a well-known risk factor, although thin people can also be at risk; a body mass index (BMI) of greater than 30 is a strong risk factor.

Keep in mind that these statistics are from studies done mostly on the Caucasian population. There may be ethnic variations. For example “thin” Asian men and women may have OSA. Recently a study was conducted at Emory University (Sleep And Heart in Asian Indians or SAHAI) in which 217 Asian Indians in the Atlanta area were surveyed regarding sleep apnea and heart disease. Among those who said they snored regularly, hypertension was seen in 37 percent, compared to 9 percent in those who said they did not snore. This risk for high blood pressure was shown earlier in Caucasians, but an important finding in our community is that the risk exists even in thin individuals.

How is OSA diagnosed and treated?

Sleep apnea is rarely caught without you first mentioning your snoring or sleep problems to your doctor. Only then will the physician suspect SA. He or she will check blood pressure, which can start out being "borderline high." The tongue and inside of the mouth and back of the throat are also examined. A diagnosis of OSA is usually made by overnight polysomnography (sleep study).

Treatment may include weight loss and positional therapy. Generally snoring and episodes of apneas are worse when sleeping on the back and also during rapid eye movement sleep (REM sleep). When sleeping on the back, one’s tongue rests further back in the throat, crowding an already overcrowded oropharynx. The diaphragm may also be pushed up by abdominal contents (this is worse in obese individuals) reducing the amount of air the lungs can hold. The combined effect of this is "hypoventilation" or less breathing than should be, resulting in worse oxygenation of the blood. SA patients should therefore be advised to sleep on the sides (tipping forward, not back) or stomach.

Try a saline nasal spray to help keep your nasal passages open. Remember that nasal decongestants or antihistamines are generally recommended only for short-term use. Avoid alcohol and medications such as tranquilizers and sleeping pills, which relax the muscles in the back of your throat, interfering with breathing.

The gold standard of treatment of OSA is CPAP (continuous positive airway pressure), which is delivered to the patient from a small machine connected to a mask worn on the nose. This is not extra oxygen but regular air that we all breathe, but under pressure. This positive pressure "stents open" the airway, preventing its collapse. While CPAP is effective in more than 95 percent of people who use it, unfortunately only half (i.e., 50percent) of people are able to use it.

Alternative treatments exist, examples being an oral appliance and various types of surgery. Generally surgery is not a first option due to the variable results.

Can OSA be prevented?

Exercise regularly and control your diet to prevent obesity. Don’t smoke. Drink only moderately. Childhood obesity is on the rise and is a risk factor for not only sleep apnea but several other health problems, and every effort should be made to guide young people toward healthy living.

So, if your spouse is bothered by your snoring or if you are feeling tired in the day, do not ignore it! Take it seriously and ask your doctor to check you for it. Then follow up with the appropriate recommended treatment for good health and, of course, a good night’s sleep.

Some of the information in this column was provided by Dr. Srinivas Bhadriraju, assistant professor of medicine at Emory University and medical director of the Sleep Medicine Program at Emory Crawford Long Hospital.

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