Avitzur, Orly M.D.
Todd J. Swick, M.D., a neurologist and Fellow of the American Academy of Neurology (AAN), knew he could no longer ignore his wife's complaints about his snoring. The tipping point was when his daughter—who had just undergone surgery—pleaded with him to leave her hospital room, where he had fallen asleep on the pullout couch, because the noise was keeping her awake.
Dr. Swick had gradually gained weight over the years. By the age of 44, he had also developed diabetes, hypertension, and a tendency to fall asleep at inappropriate times during the day. The Houston-area sleep medicine specialist knew those symptoms could be linked to obstructive sleep apnea (OSA)—and that it was time to stop disregarding them.
The diagnosis of OSA was confirmed when Dr. Swick underwent a comprehensive, overnight sleep study called a polysomnogram that records a wide range of physiologic changes during sleep, including breathing, brain function, and muscular activity. Two months after he began treatment with continuous positive airway pressure (CPAP), his blood pressure returned to normal; six months after starting CPAP, his blood sugars returned to normal as well. (See box, “Benefits of Treating Sleep Apnea.”) CPAP machines blow air at pressures sufficiently high to keep the airway open during sleep. The air is pushed through tubing and a mask that fits over (or into) the nose, where it then passes into the throat.
OSA occurs when a blockage or narrowed airway in the throat makes it difficult for air to squeeze through. This typically leads to noisy snoring, often noticed first by family members or bed partners, as in the case of Dr. Swick. OSA also causes shallow respirations (hypopneas) or lapses in breathing (apneas), each of which causes a drop in oxygen levels in the blood. This triggers the brain to interrupt sleep. In effect, the brain chooses breathing over sleep.
The cycle of hypopneas and apneas can repeat many times an hour, preventing a person with OSA from reaching vital, restorative stages of deep sleep and rapid eye movement (REM) sleep.
Dr. Swick, an assistant clinical professor of neurology at the University of Texas-Houston who has been practicing sleep medicine for the past 10 years, points out that many people with neurologic conditions—stroke, Parkinson's disease, Alzheimer's disease, multiple sclerosis, and ALS—are at increased risk of OSA. All these conditions affect the neuromuscular control of breathing and at the same time increase upper airway resistance. (See box, “Risk Factors for Obstructive Sleep Apnea.”)
If you suspect that you or your bed partner may have OSA, it's critical that you get medical help because the diagnosis raises your likelihood of having a serious health condition such as high blood pressure, stroke, diabetes, and heart disease.
Less than 15 percent of people with OSA know they have it, although the condition is common. In fact, it affects up to one in four men and one in 10 women in the United States. “OSA is an epidemic that used to be discussed in hushed tones,” says Dr. Swick, who is pleased to observe that the stigma is disappearing. And like several other neurologists with OSA, he was willing to share his experience—both personal and professional—with Neurology Now.
So when doctors are patients, what do they do?
1 SPEAK UP All of our experts emphasized the importance of discussing one's symptoms with a doctor. Unfortunately, most physicians don't inquire about OSA during routine examinations. If you are experiencing symptoms, ask your doctor if it's possible you have OSA. (See box, “Symptoms of Obstructive Sleep Apnea.”)
“Sleep apnea ruins two people's sleep,” observes Bruce H. Cohen, M.D., director of neurology at Children's Hospital in Akron, OH, and a Fellow of the AAN. Dr. Cohen admits he was initially embarrassed by his own diagnosis of OSA and understands why patients may be reluctant to bring it up. His OSA became so severe at one point that he was unable to drive to and from work due to fatigue. He often pulled into gas stations on the way home, setting his alarm clock for five minutes in order to nap. When he finally underwent a sleep test, it showed that he stopped breathing every 30 seconds during REM sleep. “We owe it to our spouses to get properly diagnosed,” Dr. Cohen says, recalling that his wife's mood improved when he finally began treatment.
2 PRACTICE CPAP BEFORE BED If you are diagnosed with OSA, your doctor will likely recommend CPAP, the treatment of choice for most adults with OSA. Unfortunately, many people don't take the time to get accustomed to using the devices, which is what initially happened to Dr. Swick. Like more than half of his patients, he found himself ripping off his mask in the middle of the night for the first few weeks of use. He then decided to spend 30 minutes each night—before going to sleep—learning how to breathe through his nose with the mask on.
“It's not unusual for patients to start to panic when they open their mouths to breathe and feel the pressure rushing out of their mouth,” he notes, explaining that the sensation can be so disturbing that it causes people to gulp, swallow air, and develop stomach bloating. He now tells each patient to practice for half an hour before bedtime for as long as it takes to get used to breathing through the nose while wearing the mask.
3 FIND THE RIGHT FIT Neurologist and AAN member Marc Raphaelson, M.D., a sleep specialist who practices in the Washington D.C. area, was diagnosed with OSA several years ago after his wife expressed serious concerns to him about his snoring. Dr. Raphaelson notes that shopping for the right mask can be as tricky as finding the proper fit in shoes chosen from a catalog.
“Since they cost in the range of $150, you don't just buy a dozen to try,” he says. He recommends that his patients select a mask with a 30-day replacement warranty and that they try two masks during that period. This also applies to finding a mask replacement, which he says should be done every six months or so, trying an alternate style or brand of mask with the same return option.
Most insurance companies cover sleep testing and treatment, which includes CPAP.
4 LOSE WEIGHT When sleep specialist Mark R. Ippolito, M.D., a neurologist and AAN member in Charlotte, NC, began to see a large number of patients with OSA, he recalls thinking, “Hey, that's me!” in response to their stories. Fatigued during the day and fighting to stay awake on his commute home from work, Dr. Ippolito began to suspect that his snoring could be something serious.
His suspicions were confirmed by home testing, which has become increasingly reliable over the years. He started CPAP, but what he really wanted was a “cure.” He eventually decided his body mass index (BMI) of 30 was something he could change. After losing more than 30 pounds, he retested within the normal range of sleep. Indeed, almost all the doctors who spoke with Neurology Now made weight loss a priority.
5 SAY NO TO THE NIGHTCAP Several of the experts we interviewed mentioned that alcohol, especially before bedtime, worsens OSA. Studies show that alcohol impairs breathing—even for otherwise unaffected people—but significantly worsens the problem in people with OSA.
“A small beer or glass of wine is fine on occasion if you have OSA, but not at bedtime,” says neurologist and AAN member Stephen D. Feren, M.D., a sleep specialist who sees veterans with a variety of sleep disorders at Charles George Veterans Affairs Medical Center in Asheville, NC.
6 STAY OFF YOUR BACK Neurologist and AAN member Mark Eric Dyken, M.D., director of the Sleep Disorders Center at the University of Iowa College of Medicine in Iowa City, IA, had been a stomach sleeper until a doctor advised him to sleep on his back following a severe neck injury. Dr. Dyken recalls awakening several nights in a row gasping for air after dreams in which he believed he was drowning. It was his physician wife who, pointing out that he was also snoring loudly, suggested that he may have OSA, a hunch that was later confirmed at his university sleep lab.
The sleep study revealed that all his breathing lapses occurred while he was lying on his back. After losing more than 50 pounds, he eventually discovered that he could forgo his CPAP by sleeping on his side, a habit that he has been able to continue over the years. Dr. Dyken uses a whole-body pillow to help him stay in that position and sometimes adds a u-shaped pillow to support his neck.
This positional therapy can also be achieved by placing a wedge under the head of the bed to help prop open the airway or by wearing a nightshirt with a tennis ball placed into a sock sewn to the back to avoid lying flat. Dr. Dyken says it's a great addition to CPAP, especially for those with severe OSA and for very heavy patients who are unable to breathe deeply enough despite treatment with CPAP. But Dr. Ippolito also finds it extremely useful for patients who don't qualify for CPAP or fall below the insurance guidelines for medical necessity. “Often, these ‘walking tired’ are ignored, although they could benefit greatly from simple positional therapy,” he says, adding, “And it's cheap!”
7 KEEP A STRICT SLEEP SCHEDULE Neurologist and AAN member Meredith Broderick, M.D., a sleep specialist in Seattle, WA, recalls being one very sleepy resident during her neurology training. Although she attributed her symptoms to long work hours, Dr. Broderick found that she was still tired when she was getting a full eight hours of sleep a night. She suspected something was wrong, but she didn't fit the OSA stereotype of an overweight, older man with a short, thick neck.
Dr. Broderick then learned that thin, young people—especially people of Asian descent, like herself—may also have OSA. A sleep study confirmed her diagnosis.
Dr. Broderick has found that, in addition to using her CPAP machine, it's critical for her to maintain a balanced sleep-wake cycle, although she admits that it requires a certain amount of discipline to wake up and go to bed at the same hour, seven days a week. “If you stay up later on the weekends, sleep in on the weekends, or nap after work or dinner, things can deteriorate quickly,” Dr. Broderick says, adding, “like physical fitness and nutrition, a long-term lifestyle change is required.”
8 PACK IT TO-GO The neurologists on CPAP that we spoke with don't leave home without their machines. “My CPAP machine goes with me everywhere,” says Dr. Cohen. “It has been to India, Italy, Canada, and more than 30 states in the United States.” The child neurologist, who takes care of many patients with mitochondrial disorders such as myopathies that increase the risk of OSA, says, “I skipped CPAP one night in the last five years—on an overnight trip—but decided it was silly to have left the machine at home.” He feels so much more refreshed after using it that the only time he does not is on red-eye or overseas flights in which he sleeps upright.
Dr. Raphaelson came to the same conclusion after his own improved daytime alertness and says that his device fits very nicely into his computer bag where it goes through airport security along with his laptop without a problem.
Benefits of Treating Sleep Apnea
Treating sleep apnea improves both objective and subjective measures of sleep. After treatment, many patients report the following benefits:
* Restoration of normal sleep patterns.
* Greater alertness and less daytime sleepiness.
* Less anxiety and depression and better mood.
* Improvements in work productivity.
* Better concentration and memory.
* Patients’ bed partners also report improvement in their own sleep when their mates use CPAP, even though objective sleep tests showed no real difference in the partners’ sleep quality.
University of Maryland Medical Center. To read more, go to http://bit.ly/IWujfQ.
Risk Factors for Obstructive Sleep Apnea
According to the Mayo Clinic, the risk factors for OSA include:
* EXCESS WEIGHT. Fat deposits around the upper airway may obstruct breathing. However, not everyone who has OSA is overweight. Thin people develop the disorder, too.
* NECK CIRCUMFERENCE. A neck circumference greater than 17 inches (43 centimeters) is associated with an increased risk of OSA. That's because a thick neck may narrow the airway and may be an indication of excess weight.
* HIGH BLOOD PRESSURE (hypertension). OSA is more common in people with hypertension.
* A NARROWED AIRWAY. Some people inherit a naturally narrow throat. Enlarged tonsils or adenoids can also block a person's airway.
* BEING MALE. Men are twice as likely to have OSA; however, women increase their risk if they are overweight, and the risk also appears to rise after menopause.
* BEING OLDER. OSA occurs two to three times more often in adults older than 65.
* FAMILY HISTORY. Having family members with OSA increases one's risk.
* USE OF ALCOHOL, SEDATIVES, OR TRANQUILIZERS. These substances relax throat muscles.
* SMOKING. Smokers are three times more likely to have OSA than are people who have never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after a person quits.
* PROLONGED SITTING. Studies suggest that long periods of daytime sitting can cause fluids to shift from the legs when a person reclines at night, narrowing airway passages and possibly increasing the risk of OSA.
In addition, many people with neurologic conditions—stroke, Parkinson's disease, Alzheimer's disease, multiple sclerosis, and ALS—are at increased risk of OSA, points out neurologist and AAN member Todd J. Swick, M.D.
Symptoms of Obstructive Sleep Apnea
According to the National Institute of Neurological Disorders and Stroke (ninds.nih.gov), the symptoms of OSA include:
* Excessive daytime sleepiness (the hallmark symptom of the disorder)
* Restless sleep
* Loud snoring, with periods of silence followed by gasps
* Falling asleep during the day
* Morning headaches
* Trouble concentrating
* Mood or behavior changes, anxiety, and depression
Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation.
Take an Online Sleep Apnea Test!
Several online questionnaires can help you check if you or your bed partner might have OSA. The STOP-bang questionnaire, for example (http://bit.ly/JGNfi3) can screen the condition in seconds, and the Epworth Sleepiness Scale (umm.edu/sleep/epworth_sleep.htm) asks eight questions to determine your degree of daytime sleepiness. However, it's still important to speak with a neurologist to see if a sleep test is appropriate—that decision should be made after a physical exam and medical history is taken.