by Louise Graham, Ph.D.
Marilyn, John’s wife, complains that her 50-year-old
husband is always tired during the day, despite eight
hours of sleep, that he has decreased motivation, diffi-
culty concentrating, is forgetful, grumpy, too tired to do
much of anything and worst of all, snores so loud she
can’t sleep.
A second man Bill, a 58-year-old male who smokes
and is obese, complains that he “wants to get things
done but is too tired” and has memory problems. His
concentration is poor, he feels “keyed up” and reflects
that he almost nods off at times while driving.
You might think these people are depressed or anxious, however
the culprit may be sleep apnea.
Sleep apnea occurs in approximately
1–9 percent of the population.
It is more common in males than
females, an estimated range from 2:1 to 10:1
and the incidence increases with age.¹
Apnea is Greek for “want to breathe.” It is
the cessation of breathing for 10 seconds or
longer. “Hypopnea” also is Greek and means
“hypo” beneath and “pnea” means breath. So a
hypopnea is a decrease in airflow by 50 percent
and ultimately a decrease in the amount of
blood oxygen saturation with an increase in
carbon dioxide.² Types of apnea are the following;
obstructive, central (brain caused) and
mixed. Obstructive sleep apnea (OSA) is the
most common. The cause of OSA is that the
soft tissue in the rear of the throat collapses
during sleep, which results in a cessation of
breath (see figure 1). The airway is maintained
open by muscles in the pharynx dilating or
pushing open the airway. Sleep apnea patients
often have small pharyngeal airways, which
may be due to obesity or structural abnormalities.
Dilator muscles are able to compensate
during wakefulness but not during sleep. This
inability to compensate results in an increase
in carbon dioxide, which is an alarm to the
brain signaling the need to breathe. This triggers
an arousal from sleep and the restoration
in breathing until the next apnea episode
occurs. This may occur as often as a hundred
times and hour and for periods as long as a
minute or more.
Sleep apnea is measured by the Apneas-
Hypopnea Index (AHI) which equals the
number of apneas + hypopneas divided by the
number of hours of sleep. It is also called (RDI)
Respiratory Disturbance Index. When an individual
has an AHI equal to or greater than 5 it
is considered abnormal.
Sedatives and alcohol will exacerbate the
apnea by having a relaxing effect on the dilator
muscles. Snoring, obesity and daytime sleepiness
are associated with OSA. The extra tissue
from obesity results in a smaller pharyngeal
airway. Snoring increases with age and lying
on one’s back is more apt to cause airway
collapse.³
Risk factors associated with sleep apnea
include obesity, especially upper body fat; a
large neck, more than 17” for a male and 16”
for a female, a recessed chin and aging. Males
are more at risk for sleep apnea than females.
Smoking, alcohol and sedative use increase the
risk. If you have a family member with sleep
apnea, you are more likely to have it. Some
ethnic groups have higher rates of sleep apnea
such as African-Americans, Pacific Islanders
and Mexicans. Cardiovascular correlates for
sleep apnea include arrhythmias, myocardial
ischemia, stroke, coronary heart failure.
Hypertension rates increase by 50 percent with
an associated increase in mortality rates.
Motor vehicle accident rates, both fatal and
nonfatal, and also work related accidents are
higher in sleep apnea patients.4 Elevated rates
of depression and anxiety have been noted in
sleep apnea patients.
Do you have sleep apnea?
Are you sleepy, despite a reasonable number of
hours of sleep, lack motivation, have concentration
difficulties, memory problems and are
irritable? Do you fall asleep during the day if
you are sitting in a chair at work, waiting for
someone or an event to begin? Have you ever
fallen asleep while driving, at a red light or had
difficulty staying awake while driving? Do you
snore? Ask your bed partner if s/he has noticed
a cessation in breathing followed by a loud
snore or snort.
People with sleep apnea are usually not
aware that they cease breathing. Often people
with sleep apnea request a sleeping agent from
their health care practitioner or take an herbal
aid to help them sleep and think this solves the
sleeping problem. The sleep apnea is still continuing,
only now the person is not aware of it.
Is the snoring so loud it disturbs your bed
partner?5 Marital discord may result from the
irritating snoring and many couples end up
sleeping in separate rooms.
Are you overweight, have a large neck? Do
you have hypertension? Check for relatives
who have sleep apnea, although a relative may
be undiagnosed. Are you depressed? Untreated
sleep apnea may place you at risk for hypertension,
cardiac problems, a stroke or possibly an
automobile accident. A pulmonary health care
practitioner can test you for sleep apnea with
an overnight painless test called a polysomnograph.
If you have another sleep disorder, it
would be diagnosed with this sleep study also.
Interventions
Medical interventions for sleep apnea include
an oral appliance, Continuous Positive Airway
Pressure (CPAP) machine or surgery. An oral
appliance is effective for mild to moderate sleep apnea. Mandibular repositioning and
tongue retaining prostheses, which are similar
to retainers, can be used. Surgery is approximately
40 percent effective in mild to moderate
sleep apnea, when the uvula and soft
palate are removed. Repositioning of the jaws
forward can also be accomplished by surgery.
Compliance with CPAP.
Two types of Positive Airway Pressure are used
with sleep apnea patients, Continuous Positive
Airway-Pressure and Bi-level Positive Airway
Pressure. Continuous Positive Airway Pressure
(CPAP) is room air pumped into the nose,
which is regulated by pressure to maintain an
open airway. The pressure utilized is determined
from the results of an overnight
polysomnograph. You can think of it as similar
to the propane gas inflating a hot air balloon.
Bi-level Positive Airway Pressure is pressure
strong enough to maintain an open airway
during inhalation and a decreased pressure on
exhalation. Deaths decreased in patients with
moderate sleep apnea when they used the
CPAP and driving performance improved on a
simulator.6 Some complaints with the CPAP
are moderate to severe mask discomfort, nasal
congestion, rhinorrhea (watery discharge from
the nose) and some people with claustrophobia
experience a sensation of not being
able to catch their breath.
The long-term effects of CPAP on patient
functioning were investigated by comparing
80 patients with OSA to 80 matched controls
on a number of measures prior to and after the
CPAP usage.7 Results indicated that before
their treatment sleep apnea patients were more
anxious, somnolent and depressed than the
controls but not significantly different from
the controls after CPAP treatment. In a hospital
study of 43 male veterans treated with CPAP at
six-month follow up that their scores on a
phobia measure were significantly lower after
treatment and their long-term depression
scores had also decreased.8 It was determined
that CPAP mask comfort was a major factor,
which determined CPAP compliance. Thirty-
five percent of the people who rated the CPAP
mask at a 4 or higher for usage comfort on a
scale from 1–5 used the machine four hours or
more per night when compared to 0 percent of
the people who rated the mask comfort at less
than a 4 on this comfort scale. Prescription
medications can decrease the early rhinorrhea
and nasal congestion often experienced by
some patients.
There are many different types of masks.
Resistance to using the mask, even after the
physical aspects of the CPAP machine have
been solved, could be secondary to a previous
traumatic event, which is unresolved psychologically.
Some patients who were highly
resistant to mask usage had a prior negative
sensitizing experience involving breathing. An
example was an 80-year-old man whose sister
closed him in the rumble seat of a car, when
they were children. He felt trapped and had a
sensation of being unable to breathe. Another
man, while working with electricity, received a
jolt that knocked him to the floor. He said he
could not breathe for a short period of time.
These incidences involved a feeling of not
being able to breathe and an inability to catch
one’s breath. The air pressure from the CPAP
machine can make a person feel as if it is diffi-
cult to breathe through the nose while keeping
the mouth closed against the air pressure.
People who are uncomfortable in certain situations,
where the thought of having difficulty
breathing caused them anxiety and discomfort,
may need the phobic issue addressed
prior to being CPAP compliant.
Behavioral Interventions
Weight loss training can possibly alleviate the
problem in mild and moderate OSA patients
by reducing the fatty tissue in the pharyngeal
airway, thus enlarging the diameter of the
airway. Increased energy, concentration,
memory and a restful feeling can be positively
reinforcing when this method is successful.
Sleep position training can be helpful in
some mild cases of OSA. Training the person
to sleep on his side instead of on his back can
be helpful in mild cases.9 A T-shirt with a
pocket on the back in which several tennis
balls are placed will serve as a stimulus for the
person to roll onto his side. A gravity activated
position alarm, which sounds if the
person remains on his back for more than 15
seconds, is available.10 There are also positional
sensors available that wake a person
sleeping on his back by delivering a mild
shock and awakening them.
Alcohol abstinence is definitely recommended
for a person with sleep apnea. Alcohol
increases the frequency of upper airway
obstruction by selectively reducing the motor
activity of upper airway dilator muscles, which
can result in an airway collapse.11 Alcohol can
also decrease the arousal response to apnea,
which then may decrease oxygen to the brain.
Sedatives have similar effects on the dilator
muscles. People will often report that they are
sleeping better with this medication and they
may incorrectly believe they don’t have sleep
apnea any longer. Smoking cessation is also
recommended.
Resources
The American Sleep Apnea Association (ASAA) is a nonprofit organization with the mission to reduce injury, disability and death due to sleep apnea. Enhancement of the person’s quality of life with sleep apnea and education are also major efforts of the organization. ASAA has a support group network
called Alert, Well And Keeping Energetic (AWAKE) that has 200 groups in all 50 states.
Visit their Web site at: www.sleepapnea.org or
call: 202-293-3650.
Other resources:
American Academy of Sleep Medicine at
www.aasmnet.org and the American Sleep
Disorders Association at www.asda.org
Both of these organizations provide free single
copies of wellness booklets to the public.12
LOUISE GRAHAM, Ph.D. is an assistant
professor in the Graduate Counseling
Program at Bridgewater State College, has a
clinical appointment at Harvard Medical
School and hospital privileges at the V.A. New
England Health Care System.
References
- Epstein, L. J. and Weiss, W. Clinical consequences of obstructive sleep apnea. Seminars in Respiratory and Critical Care Medicine, (1998).Vol. 1B9(2), pp. 123–32.
- Ibid.
- Pressman, R. and Orr, W. C. Understanding sleep, the evaluation and treatment of sleep disorders. Washington, D.C.: APA (1997).
- Ibid.
- American Sleep Apnea Association Retrieved May 21, 2002, from http://www.sleepapnea.org
- Epstein and Weiss.
- Mu~noz, A., Mayoralas, L. R., Barbye, F., Pericyas, J., and Agusti, A. G., “Long-term effects of CPAP on daytime functioning in patients with sleep apnea syndrome.” European Respiration Journal, April, (2000). Vol. 15(4), pp. 676–81.
- 8. Epstein, L. J., Graham, L., Turner, A., Larkin, E., Garshick, E., Ayas, N., Hough, S. and Brown, R., Comparison of two methods for achieving compliance. Paper presented at ALA/ATS International Conference, Toronto, Canada (2000).
- 9. Cartwright, R. D., Lloyd, S., Lilie, J. and Kravitz, H. “Sleep position training as a treatment for sleep apnea syndrome: A preliminary study.” Sleep, (1985). Vol. 8, pp. 87–94
- 10. Ibid.
- 11. Pressman and Orr.
- 12. Pascualy, R. A. and Soest, S. W., Snoring and Sleep Apnea, New York:Raven (1994).
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