Each night, countless people settle into bed for a night of sleep that is anything but serene. Throughout the night, they snore and struggle to breathe, resulting in chronic fatigue and an increased risk of heart disease, hypertension, and even diabetes. This disorder, known as sleep apnea, is believed to affect approximately 30 million Americans, of which a very small fraction, approximately 4%, have been diagnosed.
This article tells you what you need to know about sleep apnea, its impact on physical and mental health, the importance of early detection, and management, and its impact on quality of life.
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What is Sleep Apnea?
Sleep apnea is a condition where breathing repeatedly stops and restarts during sleep, ultimately leading to decreased blood oxygen levels (hypoxia). There are three primary types of sleep apnea: obstructive, central, and complex.
- Obstructive Sleep Apnea (OSA): OSA is the most common type of sleep apnea, and it is caused by the collapse or restriction of the airway, specifically when the muscles in the back of the throat fail to keep the airway open during breathing. Common symptoms of OSA include daytime fatigue and somnolence, snoring, waking from sleep gasping or choking, headaches in the mornings upon waking, and chronic diseases such as hypertension and depression. While anyone can develop OSA, risk factors include conditions that block the airway such as obesity (fatty neck), narrow airway (e.g., caused by enlarged tonsils), older age, male gender, smoking, asthma, and diabetes.
- Central Sleep Apnea (CSA): CSA is not as common of a cause as OSA. CSA occurs when the brain does not send the appropriate signals to the muscles that control breathing. Symptoms of CSA are similar to those of OSA. CSA is often a secondary cause of medical conditions such as heart failure, stroke, amyotrophic sclerosis, myasthenia gravis, or the use of certain drugs such as opioid pain medications and narcotics.
- Complex Sleep Apnea Syndrome (CSAS): CSAS, also referred to as treatment-emergent sleep apnea, is a combination of both obstructive and central sleep apnea. It often occurs in patients being treated for OSA with continuous positive airway pressure (CPAP) therapy. In contrast to OSA, during CSAS a person has pauses in their breathing during sleep despite having an open airway.
Cardiovascular Consequences
Sleep apnea can lead to cardiovascular problems such as hypertension, heart disease, and arrhythmias. Let's break down how this happens.
- Oxygen Deprivation - When someone has sleep apnea, they stop breathing for short periods throughout the night. This ultimately results in hypoxia which can lead to damaged heart vessels, making it difficult for the heart to effectively pump blood. Think of it like trying to run a race while holding your breath, your body gets stressed and doesn't work as well.
- Hypertension - Each time the person with sleep apnea wakes up gasping for air, their body experiences a small shock, triggering the sympathetic nervous system, making the heart beat faster and raising blood pressure. Over time, repeated triggering of the sympathetic nervous system results in chronic hypertension.
- Heart failure and arrhythmia - The effort to breathe against a blocked airway can lead to the heart's chambers (ventricles) enlarging and the inability of the heart to pump blood effectively, causing heart failure. Furthermore, the combination of decreased oxygen and increased sympathetic activity may disrupt the heat’s electrical stability and interfere with the heart’s normal sinus rhythm, resulting in an arrhythmia such as atrial fibrillation.
Metabolic Impacts
Sleep apnea can affect more than sleep; it can also have an impact on the body's metabolism. This means it can influence things like a person’s blood sugar levels and how their body uses energy. Two common metabolic disorders linked to sleep apnea are type 2 diabetes and metabolic syndrome. Type 2 diabetes is a condition where the body has trouble controlling its blood sugar levels. Metabolic syndrome is a group of health issues that raise your risk for heart disease, diabetes, and stroke. Conditions associated with metabolic syndrome include hypertension, hypercholesterolemia, excess body fat around the waist, and high blood sugar.
So, how does sleep apnea play into this? The hypoxia resulting from sleep apnea can impair the body’s ability to control blood sugar levels by increasing the level of blood cortisol, a stress hormone that raises blood sugar levels. Over time, this can lead to insulin resistance, a significant factor in developing type 2 diabetes.
Mental Health, Cognitive Effects and Impact on Quality of Life
Sleep apnea affects not only physical health: it can also have an impact on a person’s mental health. One of the most common mental health issues linked to sleep apnea is depression. Studies have shown that people with sleep apnea are more likely to feel depressed. This might be because lack of sleep can make it difficult to handle stress and cope with negative thoughts.
People with sleep apnea might find themselves feeling irritable or having mood swings more often. This can strain relationships and make activities of daily life more challenging.
The stress of not getting enough good sleep can lead to feelings of worry and tension, leading to anxiety.
Sleep apnea can lead to cognitive impairments such as with memory and concentration. The brain requires consistent, quality sleep for optimal functioning, and the fragmented sleep associated with sleep apnea can hurt cognitive processes. Over time, these cognitive deficits can become more pronounced. There is emerging evidence that suggests a significant correlation between sleep apnea and an increased risk of dementia.
Sleep apnea can have a profound impact on a person’s quality of life. A person with sleep apnea may wake up feeling unrested and fatigued. This daytime fatigue can make it tough to concentrate, remember things, or be motivated to do daily activities. This can make things like studying, working, or even just paying attention in class very difficult.
Respiratory System Complications
Sleep apnea, especially OSA, can have significant repercussions on the respiratory system, worsening conditions like asthma and chronic obstructive pulmonary disease (COPD). The interplay between sleep apnea and these respiratory conditions is complex and multifactorial, involving recurrent hypoxia and sleep fragmentation.
- Asthma can be exacerbated by the presence of sleep apnea. Recurrent episodes of hypoxia during sleep can increase airway inflammation and hyperreactivity, leading to more frequent and worsening asthma symptoms. Moreover, sleep fragmentation resulting from frequent arousals can disrupt the normal sleep cycle, leading to poor sleep quality and increased daytime fatigue, which can further impair asthma control.
- COPD is another respiratory condition that can be worsened by sleep apnea. The overlap of these two conditions, known as the overlap syndrome, is associated with a higher risk of exacerbations, hospitalizations, and even death compared to individuals with either condition alone. The mechanisms underlying this relationship include the exacerbation of nocturnal hypoxemia, increased systemic inflammation, and oxidative stress, all of which can contribute to the worsening of COPD.
Diagnostic Approaches
There are several ways that sleep apnea can be diagnosed.
- Many clinicians use the STOP-Bang Questionnaire as a preliminary screening tool for sleep apnea. A clinician may also ask a person to keep a sleep diary as an initial step for assessment for sleep apnea. Common questions asked in a sleep diary include the time you went to sleep, how many times you woke up during the night, and the time(s) that you woke up.
- Polysomnography is the most commonly used and comprehensive test to assess for sleep apnea. This test involves spending the night in a facility-based sleep lab. A person’s brain activity, heart rate, breathing patterns, and movements are closely monitored while they sleep. While this test provides an accurate assessment, some potential drawbacks include the cost of the test, anxiety from being monitored and having electrodes placed on the body, and the need to spend the night at a hospital or facility that conducts the test.
- There are also home-based tests used to diagnose sleep apnea. A home-based test involves the use of a portable device that tracks a person’s respirations, oxygen levels, snoring, movements during sleep (actigraphy), and heart rate while sleeping at home. While these tests are not as detailed as polysomnography, they are less costly and allow a person to sleep in their bed, and they are still effective for diagnosing sleep apnea.
It's important to remember that while these tests can help diagnose sleep apnea, a comprehensive evaluation by healthcare professionals is necessary. An evaluation should include a thorough medical history, a physical examination, and a discussion of symptoms. The healthcare team will consider various factors, such as a person’s risk factors, the severity of their symptoms, and overall health, to determine the best diagnostic approach and treatment plan.
Management and Treatment Strategies
Sleep apnea is a condition that requires comprehensive management, involving a combination of treatment modalities to effectively reduce or alleviate sleep apnea and associated health risks. Common approaches used to treat sleep apnea are listed below.
- Lifestyle Modifications: Weight loss is recommended for overweight people with sleep apnea. This can help reduce the amount of tissue blocking the airway during sleep. Regular activity and exercise also improve sleep quality and reduce episodes of apnea. Encouraging a person to sleep on their side instead of on their back can also help. Avoiding sleeping on one's back prevents a person’s tongue and soft tissues from obstructing the airway. Reducing or eliminating alcohol consumption and smoking have also been shown to ameliorate sleep apnea symptoms.
- Continuous Positive Airway Pressure (CPAP): CPAP is a commonly used treatment for sleep apnea. This involves wearing a mask connected to a machine that delivers a continuous stream of pressurized air to keep the airway open during sleep. The cost of this therapy/device is now covered by many insurance providers, making it an affordable option. The CPAP mask and apparatus must be properly fitted to the individual. Some companies that provide CPAP offer remote monitoring. Remote monitoring can help provide feedback to the patient about their sleep as well as monitor for proper functioning and use of the device. While CPAP is highly effective in reducing sleep apnea episodes, compliance can reduce its efficacy. Lack of compliance has been attributed to forgetfulness, inconvenience, and/or discomfort in wearing the device.
- Oral Appliances and Surgery: For people with mild sleep apnea, oral appliances that reposition the jaw and tongue may help reduce sleep apnea. These devices are usually custom-fitted by a provider and help to open the airway during sleep. Lack of compliance can reduce the efficacy of oral appliances. Some reasons for lack of compliance include discomfort, dry mouth, increased saliva production, and/or pain in the teeth or jaw. If anatomical issues are obstructing the airway during sleep, surgical treatment may help remedy sleep apnea. For example, sinus surgery, uvulopalatopharyngoplasty, or maxillomandibular advancement may be used to resect or reposition the obstructing tissue.
- Behavioral and Integrative Approaches: Integrative approaches such as stress management techniques, dietary adjustments, and the use of supplements may be used as adjuncts to help improve the quality of sleep in people with sleep apnea. For example, yoga, pilates, or meditation may help improve respiratory function. Additionally, supplements such as melatonin, magnesium, antioxidants such as N-acetylcysteine, and vitamin D have been shown to improve sleep quality and sleep apnea symptoms
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Key Takeaways
Sleep apnea is a medical condition with far-reaching effects on a person’s health. It has the potential to impact everything from cardiovascular to mental health. Early recognition and treatment are essential for mitigating health risks. A combination of medical treatments, lifestyle changes, and integrative approaches can significantly improve outcomes and a person’s quality of life.
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