Health professionals commonly warn about the long-term effects of sleep apnea on patients’ health, sometimes with great result, but more often than not, patients fail to fully understand the risks involved and the major health changes they are about to face. This blog post is part of a series on disease prevention and management we will be covering in the weeks ahead to help individuals better assess their sleep health.

I may have sleep apnea… so what?

How would you feel if you had to hold your breath for 10 to 30 seconds every few minutes during daytime for 6-8 hours? Not only would it be unpleasant, but you might get very tired from undergoing such a repetitive asphyxia…. After one day of this regimen, you may very well want to stop that game, knowing it is bad for your heart… and your brain (if any is left from it!).

This is exactly what you should remind yourself if you have untreated sleep apnea. Years of recurrent hypoxia during sleep can cause or worsen high blood pressure, elevate blood lipid levels, contribute to insulin resistance and diabetes, and markedly increase the risk for heart attack and stroke. Sleep apnea may also produce ventricular hypertrophy (heart enlargement) and diastolic dysfunction (inadequate filling of the ventricle) of the heart, which can eventually progress into heart failure. 

Not only may sleep apnea be a cause of congestive heart failure, but the presence of congestive heart failure may also trigger or exacerbate sleep-disordered breathing. Below are a few recommendations for you to keep in mind… and act on!

Sleep apnea may lead to congestive heart failure… if you don’t address it!

Individuals with sleep apnea have a two-fold risk of developing congestive heart failure (CHF). Contributing risk factors for sleep apnea include age, obesity, large neck circumference, craniofacial abnormalities such as a small lower jaw, sleeping on your back, or the presence of cardiovascular disease. Current research suggests that Obstructive Sleep  Apnea (OSA) may lead to CHF independent of age, obesity, or other such common risk factors. Patients with OSA typically experience many repetitive obstructive breathing events during sleep exceeding 30 to 60 times per hour, leading to disrupted nocturnal sleep and a recurrent hypoxia. So if you experience daytime sleepiness or if any of those risk factors are familiar, get help!

Congestive heart failure may cause central sleep apnea… if you don’t address it!

Between 50% to 70% of patients with congestive heart failure develop a sleep-related breathing disorder. They are at a higher risk of dying prematurely from these breathing stoppages during sleep as their heart may not function properly when exposed to repetitive low levels of oxygen in the blood. Of the patients with CHF who later develop breathing disruptions during sleep, only a minority of CHF patients develop breathing stoppages from a mechanical obstruction to the airway as seen in OSA. Instead, the majority of them develop central sleep apnea, a condition that occurs when the brain fails to transmit the proper signals to breathe. CHF patients with central sleep apnea typically experience long apneas, which can last up to 40 seconds and have arousals only several breaths after the resumption of normal breathing. 

A potential problem of the central apneas during sleep is the negative impact it may have in CHF patients. The hypoxia may worsen the blood pressure, promote ischemia and worsen existing heart failure by causing irregular heart beats (arrhythmia). Patients are often tired or sleepy from poor quality of sleep. A recent study shows that hypoxia in CHF patients contributes to an overabundance of free fatty acids, which can lead to insulin resistance, vascular dysfunction, hyperlipidemia and dysfunction of the heart muscle. 

Get treated! 

It is essential for individuals with sleep apnea to be evaluated and treated as soon as possible to prevent congestive heart failure from developing or worsening. The gold standard of treatment consists of using Continuous Positive Airway Pressure (CPAP) to open the airway during sleep, which consequently decreases the apneas, improves blood pressure, augments cardiac output, and reduces myocardial oxygen consumption, as well as other cardiovascular complications such as atrial fibrillation. Patients who cannot tolerate CPAP may benefit from an adaptive servoventilation device which performs a breath-to-breath analysis of the patient's respiratory needs, automatically adjusts the amount of airflow it delivers and is especially helpful when central sleep apnea is present. Other treatments include weight loss and oral surgery for patients whose apnea is caused by an anatomical obstruction. Finally, oral appliances are generally not recommended in patients with heart failure, especially for patients with severe sleep apnea.

If you have sent text messages during your sleep, you may want to consider the following tips to prevent sending out embarrassing or inappropriate messages:

- Turn off your cellular phone or block incoming sound alerts from emails or texts.

- Do not sleep with your cellular phone next to your bed.

- When using the alarm clock feature of your cellular phone, place you phone at a distance from your bed.

- Since lack of sleep tends to trigger sleep texting behavior, avoid sleep deprivation by ensuring you receive an adequate amount of sleep, keep a regular sleep schedule on weekdays and weekends, and follow good sleep hygiene.

- Avoid texting immediately before going to bed.

- If you are a parent, consider asking you child or teenager to hand over the phone for the night. 

Watch Dr. Markus Schmidt speak about sleep texting on WBNS-10TV.

Moving the clock forward this weekend means loosing an hour of sleep for many. But it does not have to be. Here are a few ways to adjust to the new time zone and escape the jet lag effect:

 -Go to bed 30 to 60 minutes earlier than usual on Saturday night. Chances are you may fall asleep earlier and get the 7-8 hours of recommended sleep. If you cannot fall asleep on Saturday night because your body is not ready yet, do not stress over it. Get up, do something relaxing such as reading until your usual normal bedtime hour and then allow yourself to fall asleep again. Remember, though, that the next morning you should be getting up an hour earlier.

- On Sunday morning, get up at the same time as you usually would during weekdays. It is important to keep a consistent wake schedule to prevent significant changes in your circadian rhythm. Exposure to morning daylight will help reset your body clock. So get up and look outside your window, or better yet, if you have the courage to do so, go for a brief walk.

 - If you experience tiredness during the day on Sunday, try to avoid taking a nap since it may decrease your ability to fall asleep for the earlier bedtime later that evening. Instead, let your sleep pressure or need build during the day.  Building a sleep debt will make it easier to fall asleep earlier Sunday night.

 - Remember to always practice good sleep hygiene: no caffeine after 3:00 p.m. Avoid alcohol, nicotine, strenuous exercise in the evening, as well as electronic distractions in the bedroom (TV, computer) which tend to have an alerting effect on the brain. Keep your bedroom cool and dark, and most importantly, treat your sleep schedule as a necessity. Create a conducive environment with soothing light/music/aroma, keeping stressful thoughts at bay. Your bedroom is a place to relax, not a strategic center for your next day’s agenda.

 - On Monday morning, your body may or may not have adjusted yet… Again, go to bed at your scheduled bedtime, which should be an hour earlier with respect to the week before, and allow for the recommended 7-8 hours of sleep. Soon enough, your body will adjust to the new time. But remember, keep your sleep-wake schedule consistent and allow your body to adjust the new time change.

 -Take this sleep test to assess your sleep. If you experience chronic daytime sleepiness, consult a sleep medicine specialist to evaluate the possibility of a sleep disorder that may contribute to your tiredness. 

New research on chronic fatigue has just been published and we would like to stress again the importance of an accurate assessment before diagnosing patients with a particular disorder such as Chronic Fatigue Syndrome (CFS).

CFS is a condition of prolonged and severe fatigue or tiredness not relieved by rest, but whose symptoms can often be confused with sleepiness caused by a sleep disorder. Symptoms may include profound exhaustion, poor quality sleep, musculoskeletal pain, impaired physical and mental functioning, headaches, possible low-grade fever, and occasional painful lymph nodes among others.

Very few studies have successfully found any potential causes of CFS. However, a recent study suggests that a viral syndrome may be involved for some patients. CFS was found to be linked to a retrovirus according to results published in the Proceedings of the National Academy of Sciences.  The study analyzed the gene sequence of chronic fatigue patients and found that 86.5% carry the murine leukemia virus (MLV) in their blood in contrast to only 6.8% of healthy patients. Although these study results are helpful in elucidating potential causes of chronic fatigue, it is important to note that sleep disorders were not evaluated in this study.

In the field of Sleep Medicine, we often see patients who come to our clinic with a diagnosis of CFS given by an outside physician, only to be discovered through a comprehensive sleep evaluation that the patient actually has a sleep disorder such as obstructive sleep apnea or narcolepsy as the cause of the underlying “fatigue” or sleepiness. Once the sleep disorder is treated, the sleepiness and fatigue in many of these patients completely resolves.

Sleepiness and “fatigue” are terms often erroneously used interchangeably by patients and the medical community, likely contributing to confusion about differentiating these two symptoms. Sleepiness is associated with a physiological tendency to fall asleep or nod off when sitting inactive in a boring situation, whereas fatigue is associated with malaise or low energy but no increased tendency to nod off. Fatigue is commonly associated with many medical conditions, including hypothyroidism and depression to name a few. The distinction between fatigue and sleepiness is very important. Up until a few years ago, medical textbooks on CFS have not even included sleep disorders as part of a list of possible medical conditions that need to be evaluated before making a diagnosis of CFS.

A clear prevalence of CFS among the US population is unknown, perhaps highlighting the ambivalence pertaining to the diagnostic criteria of this disorder. At our Institute, we recommend that patients undergo a comprehensive sleep medicine evaluation to differentiate sleepiness from fatigue and to rule out a sleep disorder as a potential underlying cause. If you have been diagnosed with chronic fatigue syndrome, please seek a referral with a comprehensive sleep medicine specialist to reassess your condition. You may not have chronic fatigue syndrome. And yes, you may be helped!

There are a lot of misconceptions in the general public about the role of a sleep clinic, why patients come to seek help from a Sleep Medicine specialist, or why patients need to sleep in a sleep laboratory for an evaluation. From my own experience, when someone hears that I am a "sleep doctor," they often assume that I see mainly patients with insomnia. They are generally surprised to learn that the vast majority of my patients don't have insomnia, but instead have difficulty staying awake and can nod off too easily when inactive, such as while reading, or in boring meetings, or while driving. Indeed, most of my patients boast that they can "sleep anywhere, anytime." I often have patients say something to the effect of "Doc, I don't know why my primary care physician sent me here, because I don’t have a problem with sleep, I just can't stay awake."

These misconceptions are also perpetuated by the mainstream media or by some writers who even have a specific interest in sleep. As an example, I recently heard an interview on National Public Radio (NPR) with Patricia Morrisroe, an insomniac herself who just published a new book Wide Awake: A memoir of Insomnia. In the interview, she mentions that she had an overnight sleep study in the sleep lab and that the technician mentioned that if one of the wires used to record sleep comes off in the middle of the night, that he would quietly come in the room to fix it and, hopefully, she would not wake up. Patricia Morrisroe then goes on to say: "If I were the type of person who didn't wake up when a strange man came into my room to remove electrodes, I would not be here..."

What she failed to recognize is that the difficulty to arouse out of sleep and grogginess upon awakening are precisely the symptoms we typically find in patients who need to be evaluated with an overnight sleep study. Disorders such as obstructive sleep apnea lead to excessive sleepiness and the remarkable ability to "sleep anywhere, anytime." In fact, it is common for these patients NOT to awaken when the technician goes into the bedroom to fix an electrode in the middle of the night. Many other sleep disorders cause daytime sleepiness or fatigue, including narcolepsy, restless legs syndrome, and periodic limb movement disorder, to name a few. Indeed, insomnia can often be a symptom caused by one of these other sleep disorders since the disruptive limb movements or breathing stoppages fragment sleep and rob the patient of their "good sleep."

Excessive sleepiness or fatigue is one of the most common symptoms shared by many of the sleep disorders. If you experience excessive sleepiness in spite of maximizing your total sleep time at night, you may have a sleep disorder. Your suspicion for a sleep disorder should be especially raised if you can't wake up even when a "strange man" comes into your room at night...

Take this sleep quiz to see if you may have a sleep disorder.

1. Do you snore?
2. Are you sleepy during the day?
3. Do you wake with a dry throat or headache?
4. Do you wake with heartburn or an acid taste in your mouth?
5. Do you have trouble falling asleep or staying asleep?
6. Are you irritable or do you have difficulty concentrating?
7. Do you have high blood pressure or other heart problems?

If you answered "yes" to 2 or more of these questions, you could have a sleep disorder. Consult a sleep medicine specialist certified by the American Board of Sleep Medicine for proper diagnosis and treatment. Yes, you may have to undergo a sleep study, but remember most chances are, you won't hear the sleep technician entering your room. Treat your sleep problem. Your health is at stake.