Sleep Apnea is syndrome in which a person repeatedly stops breathing for over ten seconds at a time.  Obstructive Sleep Apnea (OSA) occurs when the anatomy of the nose, mouth, or throat cause a blockage of air flow into the lungs.  Central Sleep Apnea (CSA) occurs when a person’s drive to breathe has been decreased, causing repeated cessation of breathing.  There are several bad effects of sleep apnea, beginning with the disturbance of sleep that each apnea can cause.  A person may be briefly awakened hundreds of times each night, feeling unrefreshed in the morning, even though they do not recall any problems during the night.  The physical effects of sleep loss go much farther than fatigue; sleep deprivation has been shown to worsen inflammation and decrease the effectiveness of certain immune processes.  In addition, obstructive sleep apnea can aggravate high blood pressure, making it harder to control, perhaps even hastening the development of high blood pressure.  There is also a significant increase in the rate of stroke, cardiac arrhythmias, heart attacks, and symptoms of GERD in association with obstructive sleep apnea.

Sleep apnea is currently estimated to occur in 5-7% of the male population and 2-3% of the female population of the U.S., though those numbers are probably low due to under diagnosis and the exclusion of milder (but still medically significant) types of disturbed breathing during sleep.  The likelihood of developing sleep apnea increases with age, reaching its maximum between the ages of 40-60 years.  Disturbed breathing during sleep also accompanies many medical and neurological conditions, worsening sleep and further worsening daytime function.

The tendency toward obstructive sleep apnea is greater in men, in part because they have ticker airways (recall the bigger Adam’s Apple that you see on the front of a man’s neck), but also because men have broader necks.  There is a significant risk of obstructive sleep apnea with obesity, and symptoms may appear or worsen long before a person appears over heavy.  Symptoms worsen with the use of sedative medicines or alcoholic beverages in the hours before sleep, because these further relax the throat.  Obstructive sleep apnea may also occur in slender people who have a small jaw or a chin that is positioned back a bit.

The most accurate way to diagnose sleep apnea is through an overnight sleep study called a polysomnogram (PSG).  This procedure is described in our testing section, and simply involves the placement of electrodes and special sensors over the skin to watch many physical processes as a patient sleeps.  These studies can be done in patient’s homes with a sleep technologist in attendance, under some circumstances.  Sleep studies that are done without technologist supervision are considered screening studies, and are not covered by insurance, though they may help to direct later testing in the sleep lab.

The most effective treatment of obstructive sleep apnea is the nightly use of continuous positive airway pressure (CPAP), in which a continuous stream of pressurized room air is sent through a small mask over the nose or mouth, acting as a sort of “air splint” that keeps the airway open.  Effective CPAP will completely eliminate snoring and apnea, allowing for a continuous breathing and an uninterrupted night of sleep.  CPAP may take some getting used to, but with the help of dedicated staff at a sleep center, or a respiratory home care company, a person’s comfort with the equipment can be improved.  Some patients wonder what their spouses will think about the equipment, but most spouses are pleased with the change from snoring and restlessness to a quiet night of sleep.

Some people are helped simply by the use of a dental device that slightly repositions the jaw or tongue.  These devices are easily obtained through local dentists, and may be used in addition to CPAP in very severe cases.  Some people use lubricating oral sprays to decrease snoring, but these will not help to treat sleep apnea.  Some people improve in their breathing when a nasal steroid spray or even a salt water nasal wash is tried, but these approaches are mostly only effective for the mildest of symptoms.

Surgical treatment to change to inside anatomy of the nose, mouth, or throat may be effective for a select group of patients who have a clear, isolated area of obstruction causing their sleep apnea.  The overall success rates for such surgeries are modest, especially when considered over a longer period of 5-10 years, but there are cases in which a profound improvement in symptoms can be seen over the long run.

Narcolepsy is a neurological disorder in which the most prominent problem is daytime sleepiness.  Excessive daytime sleepiness is almost always the first symptom to appear, and it may be present for several years before any other symptoms occur, such as brief episodes of muscle weakness (“cataplexy”), awakening with a brief feeling of inability to move (“sleep paralysis”), and with hallucinatory symptoms (sound, sight, or skin sensations) that occur during drowsiness.  It usually becomes symptomatic in early adulthood, but a person may be able to adjust to the symptoms for a period of time, delaying diagnosis.  The symptoms can range in intensity from mild sleepiness that requires no medical therapy, to sudden bouts of sleep attack causing physical collapse.  It is estimated to occur in one out of 1500 otherwise normal people, but it is seen somewhat more often than that in people with neurological disorders or head trauma.  There are two fundamental problems at work in narcolepsy: the impairment of ability to stay awake, and a tendency to proceed too quickly into dream (REM) sleep.

Idiopathic hypersomnia is less common, and is also seen with greater frequency in neurological conditions.  Daytime sleepiness is the only symptom in idiopathic hypersomnia, occurring despite large amounts of sleep at night.  There is no disturbance of dream (REM) sleep in idiopathic hypersomnia, simply constant sleepiness that impairs daytime function.

In either of these conditions, the diagnosis can only be made by a combination of sleep studies, including a noctural polysomnogram (PSG) to rule out other sleep disorders, and a sleep test that involves multiple naps the next day.  Treatment of these conditions may include a combination of change in daytime habits and the use of daytime stimulant medication, and in narcolepsy, other medications may be used to prevent the attacks of muscle weakness.  It is expected that treatment will need to be adjusted and/or changed over time.

People who have difficulty falling asleep or staying asleep more than a few nights a week have insomnia.  Acute insomnia may occur in the setting of exciting, upsetting, or stressful life events, and is limited to a few weeks at most.  This may occur several times in a person’s lifetime, and occurs in over 70% of the population at some point in their lives.  Chronic insomnia, defined as a recurrent and persistent problem lasting over three months, affects up to 17% of the population, worsening quality of life and causing untold losses in productivity.  The effect of insomnia on many medical conditions, and the cost of medications used to treat insomnia represent areas of considerable concern.

Insomnia may occur as a primary symptom (in the absence of any known medical cause) or a secondary condition (caused by some other physical problem).  Insomnia is a probably a combination of “learned” sleep disturbance and a physical (neurological) tendency toward easily disturbed sleep.  In cases of chronic insomnia, it may not be enough to assume that the condition is simply “a bad sleeper”; there may be an underlying, treatable condition that is causing or worsening a person’s insomnia.  For this reason, a nocturnal sleep study may sometimes be used to provide more information when initial attempts at treatment are not successful.

Most people who develop insomnia are treated with short-acting sedative (hypnotic) medications, and these are well-suited for acute insomnia.  They are less effective and less desirable for the treatment of chronic insomnia, though they may supplement other treatment approaches.  The single most effective therapy for chronic insomnia is Cognitive Behavioral Therapy, which is usually overseen by a psychologist.  This treatment includes a variety of behavioral and thought techniques that improve sleep over time, especially when combined with changes in daytime habits that may be adding to sleep disturbance.  Other therapies include biofeedback or neurofeedback training, both of which improve a person’s ability to adjust their internal physical environment in a way that favors relaxation and sleep.

Our brains and bodies respond to an internal clock that has developed with our time on Earth.  The internal cycle lasting approximately 24 hours is called a circadian rhythm, and it helps to regulate when sleep is best obtained.  A person’s circadian rhythm is greatly affected by many environmental cues, especially daylight.  It can also be adversely affected by dramatic changes in environmental cues, and can become sufficiently disturbed that regular sleep is difficult or impossible to obtain.  The treatment of circadian rhythm disorders requires a dedicated, long-term approach, which may include some medications.

Our busy lifestyles now include a phenomenon that our brains could not anticipate- the ability to step on an airplane and repeatedly change the time frame of daylight and work/play behavior, resulting in the widely familiar term “jet lag”.  Jet lag usually occurs when you are crossing three or more time zones, and is worse when you travel east.  It is best treated by adjusting your behavior to minimize adverse effects of time zone changes, perhaps with the addition of well-informed use of medication or herbal supplements when absolutely necessary.  When you travel by plane across the Atlantic, for example, it is best to travel overnight, sleeping a bit if can, and remaining awake at your destination until their evening occurs.  If you must nap, try to do so for only an hour.  The first day may be hard, but you will habituate faster to your new time zone.

Unprovoked behaviors that occur during sleep are called parasomnias, and they are of two major types.  Those that occur during dream sleep are called REM parasomnias, and are less common.  Non-REM parasomnias occur more frequently, usually happening a few times during childhood, in up to one-fifth of the population.  Repeated, problematic parasomnias are less common, especially those that continue (or start) in adulthood.  The behaviors may be simple or complex, calm or agitated, lasting anywhere from a few seconds to several minutes.  Attempts to awaken the person or restrain them may result in confusion, increasing the likelihood of a bad experience.  Once the parasomnia has finished, the person will return to sleep with no memory of the event, unless they were awakened during its progress.  Parasomnias during non-REM sleep tend to occur in the first third of the night, in contrast to the rarer REM parasomnias, which occur toward morning.  In addition, most REM parasomnias do not appear until adulthood.  It is important to determine that other causes of nocturnal behaviors, such as seizures, are not occurring.  Repeated parasomnias should be discussed with your physician, and may warrant a sleep study with additional use of full brain wave (EEG) analysis.  REM parasomnias are more common in other neurological conditions, and may justify a more extensive evaluation.

Treatment of parasomnias depends on their severity, frequency of occurrence, and any underlying cause.  In the case of the most common parasomnias, they are sufficiently rare and benign that medication is not recommended.  Simply reassuring the patient and family that the condition is not dangerous is usually enough.  In occasional cases, the symptoms are more frequent or severe, and justify the use of medications on a nightly basis to help suppress them.  Such treatment should be carefully weighed against potential side effects.

Some people have difficulty miking a smooth transition from sleep to waking.  They may be confused, irritable, or have repetitive motor activities that appear similar to parasomnias.  Such problems generally do not require medication, and are best approached by changing the way in which the people (and sleep environment) accommodate the condition.