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Sleeping With The Enemy

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If an intruder suffocated you with a pillow hundreds of times a night, you'd call the police. In the case of sleep apnea, the airway blocks off and victims stop breathing for up to several minutes–but the victim has no idea it's even happening. "The body, in essence, is being assaulted by the damage done from intermittent lack of oxygen to the heart, brain and other important organ systems, and yet such an assault goes unreported. That is, patients who have these symptoms don't always have their sleep apnea corrected. Perhaps in the light of a metaphor such as the one of being assaulted by our own sleep disorder, people would take more care of their sleep. Their hearts will thank them," says Ralph Downey III, PhD, of the Sleep Disorders Center at Loma Linda University Medical Center in Loma Linda, Calif.

Truth be told, sleep apnea may well be the most significant, costly, easily treated, and least understood public health issue facing our nation. The most recent studies predict that between 50 and 65 million Americans are at "high risk" for having sleep apnea. And very few of them have the slightest idea what sleep apnea is, much less that it may be affecting their lives in profound ways.

The Basics


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Apnea is the medical term for "stopping breathing." Sleep apnea is the temporary cessation of breathing during sleep, lasting for ten seconds up to minutes in length, depriving the body of oxygen. At some point the body arouses just enough to resume breathing and disrupt sleep, but usually not enough to awaken the individual. As a result, most people suffering from sleep apnea are not aware of their condition. In the most common type, obstructive sleep apnea (OSA), the airway blocks off when the tongue and/or other soft tissues in the throat relax and the individual simply stops breathing, sometimes for several minutes. This sequence can be repeated hundreds of times a night.

Apart from disrupting normal sleep patterns, sleep apnea wreaks havoc on the victim's body due to oxygen deprivation and physiological response patterns that occur during apnea events. There is no physiological signal stronger than oxygen deprivation to the brain. When blood oxygen levels are low, the body shunts blood from any and all organs, including the heart, to be sure the brain gets all available oxygen. On top of that, the sympathetic nervous system kicks in and releases a tremendous flood of stimulants and stress hormones, such as epinephrine (adrenaline) and cortisol, resulting in the well-known "fight or flight" response to danger.

Suppose somebody were to sneak up on you in the dark and lunge at you when you least expect it. Your heart races, the endocrine system instantly pumps out inordinately powerful stimulants. Sleep apnea victims are constantly confronted with a similar phenomenon and the accompanying red alert, each time their oxygen levels drop to a certain level. Another cruel twist happens when blood oxygen levels hover just above the critical desaturation level, getting just enough oxygen on board to avoid the arousal but not enough to provide the oxygenation that the body needs to stay healthy. The desaturation graph is remarkable for a very precipitous drop around the mid to upper eighty percent range for most people with sleep apnea.

Repetitive apneic events disrupt the normal physiologic interactions between sleep and the cardiovascular system. Sleep fragmentation, with its accompanying increased sympathetic activation triggers vascular endothelial dysfunction, increased oxidative stress, inflammation, increased platelet aggregability, metabolic dysregulation and undoubtedly helps initiate and accelerate the progression of cardiac and vascular disease. Persuasive data implicate sleep apnea in the development of hypertension, and sleep apnea contribute to cardiac ischemia, congestive heart failure, cardiac arrhythmias, and cerebrovascular disease and stroke.

At least if you've been attacked by a mugger you know to avoid ever going down that dark alley again. Sleep apnea, conversely, does not tip its hand. The victim's conscious mind has virtually no recollection of the hundreds of assaults occurring during sleep every night.

It should not be surprising that common symptoms of sleep apnea include things like loud snoring and a gasping or snorting sound, high levels of daytime fatigue, irritability, depression, malaise, loss of productivity and work performance, extreme mental and physical exhaustion, loss of judgment, etc.

The Astounding Prevalence of OSA


The numbers are shocking. The most recent studies have shown that one in four adults in the United States (31% of all men and 21% of all women over 18) is at "high risk" for OSA, based on analysis of the National Sleep Foundation's 2005 Sleep in America survey. Another recent study showed that one third of all people over 18 (who visit a primary care doctor) are at "high risk" for sleep apnea. Based on the 2000 Census, that means that between 50 and 65 million Americans likely suffer from sleep apnea. This is far higher that previous estimates that projected that between 10 and 18 million Americans have sleep apnea. Increasing awareness of sleep apnea and improved survey screening tools, along with an aging U.S. population, seem to be factors in the increase in OSA prevalence estimates.

Unacceptable Human and Economic Costs


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According to the National Commission of Sleep Disorders Research, 38,000 cardiovascular deaths a year in the United States are directly attributable to sleep apnea. On top of that, sleep apnea is associated with a large number of serious, co-morbid medical and psychological conditions, such as hypertension, abnormal heart rhythm, sleep deprivation, stroke, heart disease, diabetes, depression, memory loss, poor judgment, and change in personality. As a result, undiagnosed and untreated sleep apnea victims are significant consumers of healthcare services.

In Canada, sleep apnea victims were shown to consume 23 to 50% more medical services in the five years prior to diagnosis than control subjects, with hypertension and cardiovascular disease accounting for the majority of increased costs. A recent study from Israel also showed that healthcare utilization was 1.7-fold higher by sleep apnea patients compared to the control group, with 25% of the sleep apnea patients who consumed the most resources accounting for 70% of the total healthcare expenditures. Other studies have demonstrated that successful sleep apnea treatment results in significant improvement in co-morbid conditions, including specifically cardiovascular disease, hypertension, diabetes, stroke, and depression.

Cardiovascular disease is the most significant killer in the United States, resulting in over 685,000 fatalities and $40.4 billion in healthcare costs annually. Hypertension healthcare costs in the United States are approximately $19 billion. While it is not known what percentage of all cardiovascular and hypertension healthcare costs is attributable to untreated sleep apnea, in light of the fact that between 50 and 65 million Americans are at high risk for the disease, it stands to reason that undiagnosed and untreated sleep apnea account for hundreds of millions—perhaps billions—of healthcare dollars spent treating conditions that could be more effectively and far more economically treated as a sleep disorder. The human value in savings of physical pain and mental anguish associated with invasive procedures, surgeries, and chronic disease and death cannot possibly be quantified.

Collateral Impacts


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Collateral impacts arising from 50 to 65 million clinically sleep-deprived people in the United States are incalculable. One report focusing on highway safety impacts from sleep apnea concluded that more than 800,000 sleep-apnea related highway accidents occurred in 2000, resulting in 1,400 fatalities and costing nearly $16 billion. If the same analysis were performed today using the new, much higher sleep apnea prevalence rates, the highway safety impacts would probably be twofold higher. Because extreme daytime exhaustion is prevalent among OSA victims, sleep apnea-related losses due to worker productivity, industrial accidents, clerical mistakes, sick leave, and so forth would be almost impossible to calculate but given the numbers no doubt amount to the billions of dollars annually. On top of this, the personal quality of life impacts—depression, personality changes, lack of judgment, irritability, utter exhaustion—cannot possibly be measured in economic terms.

Simple, Effective Treatment


The best news in sleep apnea is that it is a condition that is easily and economically treated. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for obstructive sleep apnea and has been proven to be highly effective in treating sleep apnea and improving a number of co-morbid conditions. CPAP therapy consists of a ventilatory device that applies positive airway pressure at a constant,

Moving Forward


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The most significant impedement for managing the public health issues relating to sleep apnea is lack of public (and physician) awareness of the disease, its diagnosis and treatment. Just to put this into context, 13,658 Americans died from AIDS in 2003 while 38,000 died from cardiovascular disease related directly to sleep apnea (and perhaps as many as 50 million Americans have sleep apnea and are unaware of their condition). Yet while virtually every teenager knows about AIDS there is almost no public awareness of sleep apnea. At the same time a little awareness on the part of the patient or his or her doctor is all that it takes for treatment to start and the suffering to end.

Unfortunately, a large number of doctors are still not very familiar with sleep apnea or its treatment. An excellent place to start (both for doctors and for individuals) is to fill out a one-page, ten question survey called the "Berlin Questionnaire" that is widely available on the Internet. This questionnaire is simple, fast, and is highly predictive of sleep apnea—the positive predictive value of the survey for people scoring as "high risk" is 89%. Sleep apnea victims often have to work hard to convince their doctor (or insurance company) to refer them for a sleep study, so a "high risk" showing on the Berlin Questionnaire might be enough to convince them to move forward with further tests. If people are not satisfied with their medical care they should get a second opinion, preferably from a sleep disorder specialist. A number of overnight screening assessment tools are also available. A formal sleep study is necessary, however, to diagnose sleep apnea and obtain CPAP treatment.