Sleep Apnea Alex Dimitriu, MD
Updated: Nov 14, 2019
An old proverb points out the difficult reality of snoring, "The one who snores will always fall asleep first!" Working as a psychiatrist and sleep doctor, it’s not uncommon for me to hear, "My partner's snoring keeps me up all night." Many of us have had nights of lying awake, listening to our partner's snoring, hoping to doze off in between the loudness. It is not as uncommon as you may think: about 30% of men and up to 10% of women snore regularly. But often beyond the snoring, we hear difficulty breathing, at times with pauses that almost sound like a choking sensation, and our frustration can quickly become concern for our partner. We find ourselves wondering when are they going to breathe again? An essential message for my patients is that sleep is as much about quality as it is about quantity. Insomnia, smartphones, work, kids and pets can profoundly impact the quantity of sleep—keeping us up late at night and waking us up too early. But there are also those of us who seem never to be able to get enough sleep. We are always tired, looking to take a nap and unable to stay awake through a movie or a book.
Several things such as noise, heat, pain, needing to use the bathroom, anxiety and sleep apnea can interfere with the quality of one’s sleep at night. Apnea, from its Latin root, means "without breath," and by definition, apnea is a pause in breathing for 10 or more seconds. So, if you can count to 10 in between your partner's snores, you've noticed an apnea. A few of these every now and then is normal (about five per hour). However, when this occurs, the brain doesn't get enough oxygen. The brain gets an alert and signals us to wake up and breathe, which is followed by falling asleep again shortly after that. This pattern can repeat multiple times each night: sleep, snore, gasp, wake, sleep, repeat. With this number of interruptions in sleep—sometimes as many as 60 per hour—serious health issues can ensue, not to mention that it can leave a person chronically exhausted.
The following features are commonly seen in people with sleep apnea and are attributed to the brain being unable to rest at night:
Daytime fatigue or sleepinessWaking up several times per nightTeeth grindingBlood pressure abnormalitiesCold hands and feetDepressionTrouble with memory and focusADHDBedwettingSleepwalking in kids (and adults)Carbohydrate craving Trouble with weight loss (sugar is a quick and easy energy source for a tired body)
Diagnosis: Diagnosis of sleep apnea almost always involves an Epworth Sleepiness Scale to determine the degree of daytime sleepiness. Scores above six are higher than normal. Doctors making a diagnosis will ask about nighttime awakenings, snoring, apneas and some of the symptoms from the list above. If the suspicion for sleep apnea is high, the next step is a sleep study. Sleep studies are done by either sleeping in a sleep lab (designed to look much like a hotel room) or at home, with an at-home sleep monitoring device. Most of these devices are painlessly connected and monitor breathing, blood oxygen levels, heart rate and sometimes brain activity. They work together to detect the stages of sleep.
Treatment: If sleep apnea is identified, the gold standard for treatment is a CPAP (continuous positive airway pressure) machine. CPAP devices have come a long way from their early versions. Today, they are quiet, small and noiseless. They are essentially room air pumps that connect to a small mask over the nose or to the mouth and nose. A light trickle of pressurized room air is applied, which helps keep airways open, resulting in a reduction of snoring and better and continuous sleep throughout the night.
In some patients with milder sleep apnea, there are dental devices that may be helpful. These devices look like a bite guard and work by moving the lower jaw forward, which, in turn, moves the tongue away from the back of the throat and improves breathing by opening up the airway. Other alternatives almost always include weight loss. Having a large, thick neck can increase snoring, and any weight loss can often improve this to some degree. Anatomy may also be a cause of sleep apnea. For some people, radiofrequency ablation of the palate and/or base of the tongue has been proven to reduce respiratory distress when sleeping. If sleep apnea is due to nasal congestion or allergies, treatment of allergies, or in some cases minor nasal surgery, can substantially improve nasal airflow. Note that mouth breathing is not normal during the day or night and is often a sign of nasal congestion. If one has nasal congestion while standing up, it usually gets worse when lying down. Another option is to sleep in an elevated position—as with an inclined bed. The trick is not to bend the neck (as with too many pillows), but rather to elevate the entire upper body at an angle of about 20-30 degrees. Many people with undiagnosed sleep apnea will actually prefer sleeping in the recliner, or with many pillows in the bedroom. Sleep apnea occurs in children; it is so important that kids be evaluated for the disorder. Some of the most memorable moments of my career have been diagnosing and treating kids with sleep apnea. These were nine- and or ten-year-olds who had significant behavioral issues and were diagnosed with ADHD. The reality is that tired kids get hyperactive, and before a formal diagnosis of ADHD is made—in children or adults—sleep apnea should be investigated. Many of the kids I saw had enlarged tonsils. Once removed, their sleep improved, and many were taken off their ADHD medications. Myofunctional therapy is an emerging field for kids with sleep apnea. The belief here is that proper use of the jaw and chewing muscles can actually move teeth and enlarge the jaw. This, in turn, provides more room for the tongue, so the airway stays open. Special braces can also be used in children to enlarge the jaw if detected early enough to allow growth to occur. Orthodontists used to remove teeth if there wasn't enough room and the teeth were crowded. In reality, the teeth are crowded because the jaw is too small. The better solution is to enlarge the jaw, which provides more room for the airway.
Health consequences of sleep apnea: There are many health risks associated with sleep apnea. Beyond the immediate dangers of being sleepy all the time, trouble with attention, focus and memory can also emerge. Many patients coming to see me for suspected depression and low energy levels turn out to have sleep apnea. I often ask about motivation versus energy, to tease apart apnea from depression, as most people with sleep apnea want to do things (good motivation), they just don’t have the necessary energy.
The health effects of untreated sleep apnea are substantial. Untreated, apnea can result in increased risk of stroke, arrhythmias (like atrial fibrillation) and pulmonary hypertension—all the result of periods of hypoxia (lack of oxygen) during the night.
If you or your partner have symptoms of sleep apnea, consult your physician for a sleep study.Sleep apnea can have detrimental and long-term health consequences and should be treated.If sleep apnea is diagnosed, try a CPAP device, a dental device, weight loss or treatment of allergies.If a child has enlarged tonsils, consult an ENT physician and discuss surgical removal.Sleep medicine is a field of study that focuses on improving people's quality of life. Both the quantity and quality of sleep have a tremendous impact on so many areas of our lives, ranging from memory to mood, to weight loss and productivity. I always have and will continue to argue that sleep should be treated like a vital sign, along with blood pressure, pulse and breathing.
https://www.ncbi.nlm.nih.gov/ pubmed/16227718Epworth Sleepiness Scale: www.sleepapnea.org/assets/files/pdf/ESS%20PDF%201990-97.pdfAt-home Sleep Apnea Testing: bit.ly/2TK88F3
Alex Dimitriu, MD
Alex Dimitriu, MD completed medical school and residency in psychiatry at SUNY Stony Brook and continued his training at Stanford Medical Center with a fellowship in sleep medicine. He is currently in private practice in downtown Menlo Park. He sees patients with a wide variety of conditions, ranging from depression to anxiety, to insomnia and other sleep disorders. He practices an integrative model of psychiatry, which aims to improve various domains of people's lives. He has always believed in the power of the mind and the power of the spirit to heal the body. He consistently encourages integrated solutions such as cognitive behavioral therapy (CBT) and brief therapeutic interventions toward a multimodal approach to treatment.
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