Sleep Apnea: Epidemic Silent Killer
It wasn’t long ago that I thought sleep apnea occurred predominantly in overweight people who snored and probably ate too much cheese. Also called the “American Sleeping Sickness”, sleep apnea in fact is a grossly under-diagnosed illness affecting both men and women, lean and overweight, with far-reaching, serious health consequences. In fact, doctors estimate that up to eighteen million Americans have moderate to severe sleep apnea, and seventy-five percent of them do not know it. This is partly because one third of those with sleep apnea have no symptoms at all. At the same time, the condition is not hard to diagnose and treat, and should be suspected and targeted far more often than it is.
So what exactly is sleep apnea, and what causes it? Sleep apnea occurs when the upper airway becomes blocked repeatedly during sleep, reducing or completely stopping airflow and thus lowering vital oxygen levels. As it turns out, there are two kinds:
Obstructive sleep apnea occurs when the tongue and palate get stuck together at the back of the throat, and shut off air flow. Many people with obstructive sleep apnea do snore, but there are many who do not.
Central sleep apnea occurs when your brain stops recognizing that it needs to keep breathing because it has gotten used to lower oxygen levels. In most cases, this is a secondary effect of long-term obstructive sleep apnea, but it can also be induced by the use of certain drugs (especially central nervous system depressants) or post-stroke.
How would you know if you had sleep apnea? What are some of the signs or symptoms? Some signs include snoring, consistently waking up tired or taking a long time to “wake up” in the morning, depression, overall lack of energy, and even an inability to lose weight despite following a diet and exercise plan that works for most people. Even the single symptom of sleeping eight hours, but waking up like a train wreck should be enough to warrant testing. Sometimes a spouse can confirm overhearing their partner stop breathing for short periods of time, and this is of course the most confirming symptom of all.
Another curious symptom of sleep apnea can be frequent nighttime urination. This occurs primarily for two reasons. First, if you have sleep apnea and are--literally--suffocating, one of the body’s involuntary mechanisms is the urge to urinate, even if you don’t have a quantity of urine. Second, if you have significant sleep apnea, and are becoming hypoxic, this condition acutely changes the pressure in your lungs, stressing your right ventricle and atrium, and causing the release of brain natriuretic peptide--a chemical that makes you pee more. In this case, the person could have a larger volume of urine.
There are two things every cell in our body needs to produce energy: oxygen and fuel. Sleep apnea arrests every single cell’s ability to get oxygen in the night. Serious illness and disease can result from years of this type of unchecked sleep oxygen deprivation. These include cardiopathies and plaque formation, behavioral and cognitive disorders, diabetes, cancer, and glaucoma. In fact, starving the brain of oxygen all night quadruples the risk of stroke!
Medical literature is also showing that sleep apnea can drive Alzheimer’s! I recently listened to a sleep apnea podcast featuring a doctor who had a patient diagnosed with early-stage Alzheimer’s. The patient came to him for help, and was--finally--diagnosed with severe sleep apnea. He had not had good restorative sleep in years. He started wearing a CPAP mask, and in time all symptoms of his “Alzheimer’s” vanished!
Low testosterone and low libido in both men and women, and erectile dysfunction (ED) in men can also be closely associated with sleep apnea. The most common cause of low testosterone is a condition called hypogonadotropic hypogonadism. This condition occurs when the brain stops producing hormones that trigger the ovaries or gonads to produce testosterone. This usually happens when the person is highly stressed (nature doesn’t want us having babies in times of great stress), and sleep apnea can be a very common stress factor triggering this condition.
Finally, dopamine levels in the brain (our neurotransmitter responsible for ambition, drive, self-confidence, and the ability to carry through with tasks) are highly affected by hypoxia, or lowered brain levels of oxygen. So low grade “symptoms” of lack of self-confidence, inability to complete tasks, and a general lack of motivation can potentially be related to sleep apnea.
Who gets sleep apnea? Sleep apnea is equally distributed among men and women. Overall there is a slightly higher prevalence in men, however menopausal and postmenopausal women outnumber their older male counterparts. Lower hormone levels can lead to a reduction in overall muscle tone, including the muscles of the throat. Loss of tone can cause the soft palate to sag, and the tongue to move toward the back of the throat, leading to congestion in the area where air needs to go.
As discussed earlier, sleep apnea can also lead to increased plaque formation, so it’s very important to get a heart scan three to five years after menopause or in older men if you are diagnosed with a sleep apnea condition. A recent study tested a group of 80-year-olds for sleep apnea. In the group, those found with sleep apnea were offered a CPAP machine (Continuous Pressure Air Pump). Forty percent of those positively diagnosed accepted the air pump. They continued to follow the progress of the sleep apnea patients, and found those without the CPAP had three times the cardiac mortality rate as those who had accepted it!
Now that we realize how acutely important it is to effectively diagnose sleep apnea as early as possible, the next question is, how is it diagnosed? There are specialized facilities for diagnosing sleep apnea, and this would be the preferred option for someone with a severe medical condition. However, there are simple screening tools that can be used at home that are far less expensive, and potentially more effective. There are clear advantages to conducting the study while you are sleeping in your own bed and home, not being watched, and under your normal circumstances.
Two options are available for purchase online. One is a wrist-worn oximeter with an oxygen sensor (usually attached to the finger) that is connected to a computer, and tracks oxygen levels at night. If these results come back showing borderline to low oxygen levels, you can consider the slightly pricier home sleep testing kit, which is usually conducted over a three day period, and includes a breathing tube and kit which is strapped to the upper abdomen. If oxygen is smooth and stable, and above 90%, you don’t have sleep apnea. Apnea is also measured on the apnea/hypopnea index--how many times an hour a person stops or nearly stops breathing for up to ten seconds. Below five is minimal, five to fifteen is mild, fifteen to thirty is moderate, and above thirty is severe.
To illustrate even more clearly the advantages of testing within your own home, is the story of another patient of the above-mentioned doctor who lived at high altitude (in Estes Park) with suspected sleep apnea. He came down a few thousand feet to test at a sleep facility (in Boulder), and tested negative. When he did a home study, however, it revealed severe sleep apnea. High altitude is, in fact, a huge exacerbating factor for both obstructive and central sleep apnea. Had this patient not tested within his own home, the sleep apnea would not have been discovered.
This brings us to our final question: how is sleep apnea treated? Would you be shocked if I told you that simply playing the didgeridoo (Australian aboriginal tubular instrument requiring a circular breathing technique) for twenty minutes a day has been clinically proven to eradicate sleep apnea? It’s true, and if you don’t believe me, take a look at this youtube video highlighting this British study. The only downside is you can’t stop! Once you stop playing the didgeridoo, the sleep apnea will return.
Most commonly, however, people are put on the CPAP, an air pump delivering continuous air/oxygen throughout the night via a face mask. Many people resist the idea of sleeping with an oxygen mask on, but newer versions of the CPAP are becoming increasingly less invasive. Also, don’t give up if at first it doesn’t “feel right”! There are tweaks to the mask and settings that can be made working closely with the right doctor that make it much easier to tolerate. As with anything else, each person must advocate for themselves.
Other alternatives are the Mandibular Advancement Device (MAD), a dental device that will do an adequate job on seventy to seventy-five percent of people with mild to moderate sleep apnea. It is important with this device to always retest after a period of time; it is not uncommon for the device to stop working after a number of years, at which time the CPAP or other solutions must be pursued. Unfortunately, many dentists do not routinely retest, so you may have to insist on this.
Expensive airway surgeries exist for sleep apnea, but in general these surgeries are traumatic, and not always effective.
Finally, what about acupuncture? Can acupuncture help improve sleep apnea? The answer is a preliminary “yes”, particularly for moderate sleep apnea! In 2006, Dr Freire of the Public Hospital of the Universidade Federal de Sao Paolo in Brazil, conducted a randomized control study of 36 participants, divided into three groups of 12 treated, untreated, and sham acupuncture. Freire and her fellow researchers found that ten weeks of acupuncture treatments of patients with moderate obstructive sleep apnea (OSA) led to significant improvement that was not duplicated in the untreated control group, or the sham acupuncture group. While ten participants dropped out, of the 26 that remained, the mean apnea-hypopnea index of the treated group diminished from 19.9 (incidents per hour) to 10.1 while it rose from 21.6 to 24.6 in the sham group, and from 20.4 to 28.2 in the control group. (Note that 10.1 incidents per hour is still considered to be mild sleep apnea, and it is unknown had these participants continued yet another ten weeks, if the index would have dropped further.)
In their article “Treatment of Moderate Obstructive Sleep Apnea Syndrome with Acupuncture”, published online by Sleep Medicine in 2006, they stated, “We have found preliminary evidence that acupuncture is effective in the treatment of OSA. This work, however, must be replicated and the observation period after treatment should be extended in order to evaluate the duration of the improvement obtained and also to establish well defined treatment protocols.”
In responding to an e-mail inquiry, Dr.Freire commented that the most dramatic finding was that acupuncture treatment led to significant strengthening of the genioglossus, or tongue muscle! After treatment, patients’ tongues were three or four times stronger than those of patients in the control group. (Tongue strength was measured by electromyography, a technique of metering electrical activity in the muscle at rest and then as it is contracted.)
More currently: a meta-analysis in April 2016 of six randomized controlled trials involving 362 subjects was conducted on the effect of acupuncture therapy for obstructive sleep apnea. Compared with control groups, both manual acupuncture and electrical acupuncture (using e-stim in addition to points) were found to be effective in the improvement of the apnea/hypopnea index and the SaO2 (measurement of the percentage of how much hemoglobin is saturated with oxygen) compared to control groups who received no treatment, or sham treatment.
More studies need to be completed to determine whether or not long-term acupuncture can be used in place of the widely-used CPAP or Mandibular Advancement Device (MAD). But it is this author’s opinion that the results might come in similar to the findings of the didgeridoo: that once the acupuncture is stopped, the symptoms will most likely worsen again. However, it might be worthwhile for someone with mild to moderate sleep apnea but opposed to use of a CPAP or MAD to explore regular acupuncture treatment, on the condition that they routinely test themselves over a period of time to ensure that these techniques are working, and that they are achieving the oxygen levels their body requires. If you happen to read this article and want to give this a try, let us know your results!