Sleep, Disrupted


FEELING VERY SLEEPY or crappy during the day—even after a good eight hours or more—could be the result of sleep apnea.  Sleep apnea treatment has helped at least two DC-area women —though neither had any idea that was the problem.

Sleep disruption may affect more than daytime sleepiness. Recent studies suggest that people experiencing early memory loss can reverse symptoms.  Taking measures to improve sleep can help clear toxins from the brain, specifically amyloid-beta proteins that have been linked to Alzheimer’s Disease.

Usually the last to be considered or evaluated among causes of daytime fatigue, sleep apnea is defined as periods during sleep when breathing stops for more than 10 seconds.  In the moderate to severe range (waking more than 15-30 times per hour), sleep apnea affects one in 15 adults, is a risk factor for hypertension and occurs in 65% of stroke patients.  Of severe cases, 75% remain undiagnosed.

Signs of sleep apnea include lack of energy, morning headaches, frequent nocturnal urination and excessive daytime sleepiness.  It has also been linked to depression, susceptibility to frequent illness and gastroesophageal reflux (GERD).

DC-area resident D.T. had several reasons for not investigating the possibility: she’d heard sleep apnea woke you up, but that wasn’t a problem for her; she also believed having a sleep evaluation meant spending a night in a clinic, which sounded “distinctly unappealing.” But most unappealing was what she thought she knew about the solution—a breathing machine that made lots of noise with a mask that looked “horrific.”

But when “pretty crummy” was how D.T. described feeling when she woke up in the morning, the immediate reaction from a retreat group was: it sounds like sleep apnea.  One by one, her preconceptions were overcome.  First, it turns out that apnea wakes you enough to start breathing again but not necessarily enough to notice.

Next, the sleep evaluation offered by her health provider (Kaiser) is done at home—“in your own bed,” D.T. said,  using a clip on the finger to test blood oxygen and a disc taped to the chest. A wristwatch-sized computer logs data to be analyzed when you return the kit.

D.T. learned she had “moderate” apnea—between 15 and 30 incidents of breath-stopping each hour.  At a 17-incident average, hers was at the low end. But, very importantly, all the incidents occurred during REM (rapid eye movement) sleep – during which her breath stopped much more often than 17 times/hour.  “Basically I was getting no decent REM sleep,” she said.

(REM sleep takes up about 25% of each sleep cycle and begins 70 to 90 minutes after falling asleep.  REM sleep helps stabilize the circadian cycle, maintain neural pathways, consolidate memories and clear toxins from the brain and is the period when most intense dreams occur. Missing out on REM sleep interrupts all these processes.)

Besides interrupting sleep, low blood oxygen due to apnea can increase heart and breathing rates and cause anxiety, restlessness, fatigue and headaches.  Severe hypoxia can damage the brain, liver and other organs.  The most alarming finding for D.T. from her sleep study was that her blood oxygen levels fell as low as 67%.

The treatment generally offered for anything above mild (15 incidents/hour) sleep apnea is the CPAP (Continuous Positive Airway Pressure) machine that pumps oxygen through a hose into the nose.  Among the choices that included a nose-and-mouth mask, D.T. chose a mask that covers her nose.

A few weeks into treatment, results are good. She feels less sluggish when she wakes up and better throughout the entire day, especially in the late afternoon when she no longer feels “the urge for a nap or the desire to just veg.” And, going without it for one night, D.T. said: “Big mistake. Same sluggish, super-crummy-but-not-sick feeling as before I started this.”

For A.F., who has been using a CPAP machine for almost 10 years, the difference was dramatic after the very first night, and even one night without it caused enough problems on a four-day business trip that she had a machine overnighted.

“For me, it was huge,” A.F. said.  “Now I have so much more energy during the day,” unlike before when her kids often said, “Mom, you’re so tired.”  Also, A.F. frequently had a sore throat or felt like she was getting sick.  Her sleep study showed 19 incidents/hour.

Noting that she was the one who kept asking for an evaluation, A.F. advises: “You need to be your own advocate.”  Her doctors kept suggesting more exercise and a better diet; she also tried typical treatments like thyroid medication and a small device worn over the nose, as well as drinking lots of coffee all day.

Obstructive sleep apnea (OSA) is most often caused by collapse of the upper airway when muscles controlling the soft palate and tongue relax.  OSA occurs more often in those who are overweight and those with a large neck circumference, but also in people without those physical attributes and in those with a family history.  Incidence increases with age and for post-menopausal women, along with behaviors like smoking and drinking alcohol.

Mild apnea sufferers who cannot tolerate the CPAP machine —because of the noise or discomfort—can try a mechanical device in the mouth that moves the lower jaw forward during sleep to help keep the airway open, known as OAT (oral appliance therapy) or MRD (mandibular repositioning device).

D.T. notes a few weird effects of using the CPAP: If you open your mouth, air streams out and bubbles emerge from your mouth if air pressure builds up.  While she likes the humidified air going into her nose, her lips are “very dry” by morning.  And there’s the inconvenience of regularly needing to clean the machine’s components, from once weekly to every day.

Another reason for trouble tolerating CPAP is complaints from sleeping partners.  The latest version A.F. uses is noisier than before, she said.  On the other hand, needing the machine means she is given her own room whenever possible when traveling with friends.  And at home, her boyfriend also has a CPAP, as did a previous boyfriend.

Because the diagnosis is not uncommon and many feel well rested after treatment, it might just be worthwhile for anyone experiencing daytime fatigue to take the test.

—Mary Carpenter

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