Treating the “Asymptomatic” Sleep Apnea Patient

An asymptomatic sleep apnea patient, one who clearly demonstrates the disorder on objective testing yet reports no clinically relevant symptoms, poses one of the more common challenges to sleep specialists.

The two most common types of these “no symptoms” patients are those who truly appear to have no symptoms and those who are experiencing various forms of denial or ignorance about potential symptoms. We’ll discuss the latter group first because they are are easier to manage; whereas the former group borders on the impossible at times.

Sleep apnea patients who believe they do not suffer any symptoms, universally report their sleep is just fine, asserting they experience good sleep quality, refreshing feelings upon awakening in the morning, and minimal to no daytime fatigue or sleepiness. They also deny insomnia or related signs of sleep fragmentation. Not uncommonly, these patients do report symptoms or conditions often linked to sleep apnea such as nocturia, hypertension, heart disease and arrhythmias, and chronic allergies or congestion.

So, how is it these individuals can suffer objectively diagnosed sleep apnea even in the moderate to severe range, and often with oxygen desaturations into the 80% range and yet have no hint in their conscious awareness something is wrong with their sleep?

No one set explanation can paint a full picture for all these individuals, but there are several factors that show up repeatedly in this patient cohort. Among the first things you may notice about these individuals is more often than not they are men. And, what often accompanies this presentation is an unusually demanding lifestyle. For example, most of the men I have treated who deny symptoms often are hard-working individuals, with intense daily schedules, and very demanding job or personal responsibilities. In short, these folks have no time to experience daytime fatigue or sleepiness, let alone pay attention to the possibility of such problems. In effect, they have the drive, ambition, or simply the adrenalin to push through any set of circumstances to get done what needs to get done. Some will actually report how active they are during the waking hours to the point of always being on the go and rarely if ever sitting down to take a break or relax. Some might be aware that a brief break in the action might result in an ephemeral nap, but they would not connect the zzzots when this scenario plays out. 

Obviously, some of these patients are ubiquitous caffeine consumers in the form of coffee, tea, or chocolate in the form of drinks, food or even pills. If you were to inquire about the rationale for the caffeine intake, the answer is always, “I like it” or “it tastes good.” Many of these patients would likely transform into very drowsy and dangerous drivers if they suddenly ceased caffeine intake, but if one were asked what would occur if coffee consumption was reduced to zero, most answer “nothing would happen,” which is why we never recommend this experiment for safety’s sake. 

Nonetheless, the good news is these types of individuals if persuaded to use PAP therapy will frequently return in follow-up with a big smile on their faces and even a bigger epiphany in their minds, because they were able to clearly and correctly make the comparison between what they thought was their abounding energy levels pre-CPAP with their new invigorated selves post-CPAP. In other words, these individuals will actually declare they were much more tired or sleepy or drained than previously suspected, and they profess gratitude for their spouses, friends and physicians for coaxing them into treatment. Often, we need to educate them on the relationships between nocturia or hypertension or cardiac arrhythmias to build momentum to push forward, and most people over time find their curiosity piqued by the possibility of reducing their trips to the bathroom, or lowering their blood pressure, or stabilizing a heart rhythm. 

As above, a major caveat to this group occurs among those who imbibe high amounts of caffeine. While the caffeine impacts their energy level in such dramatic fashion (despite the patient not realizing it), these individuals may be unable to discern improvements in daytime fatigue and sleepiness. For them, you can only hope some other symptom abates in ways that catches the patient by surprise and clues him into the obvious connection to his newly diagnosed sleep apnea.

Among the other and more entrenched group of individuals, they not only manifest no other symptoms to address, but most importantly, they really do appear to be without daytime fatigue and sleepiness. They may not even be regular users of caffeine except for a notable bolus in the morning to overcome sleep inertia, but caffeine throughout the rest of the day may be absent or negligible.

Without genuine symptoms, hidden or otherwise, why would a patient agree to deal with the cumbersome PAP contraption when for all appearances everything seems just fine? Most of these patients reject PAP therapy. Few of them listen to an argument like, “over time it may prevent your blood pressure from rising,” or “over time, it will protect you from heart or stroke problems.” Of the several thousands of sleep apnea patients I have treated since opening Maimonides Sleep Arts & Sciences in 2002, the number of patients of this type who start and stay with PAP therapy is less than a handful. It almost seems as if these men (again usually males fit this mold) have some cognitive differences from the more common sleep apnea patients. Some of them seem to be more alert as if biologically their brain’s reticular activating system is geared toward more wakefulness while awake compared to many people with or without sleep disorders who suffer some degrees of daytime sleepiness no matter what. These folks may also manifest a very concrete personality type, not so much as being resistant to the use of PAP itself, but rather, having experienced such good health for most of their lives, it is too jarring to accept something is “wrong” when in fact everything feels “right.”

I rarely make much effort to convince these individuals to move forward with PAP therapy unless they show any interest in connecting the sleep condition to any findings or concerns they may have about their heart. The more common discussion centers around what to look for in the future for signs that sleep apnea treatment should be reconsidered. Again, the useful clues would be more trips to the bathrooms, blood pressure levels creeping up, or an emerging echocardiogram finding of early right ventricular hypertrophy despite any other cardiac symptoms or findings. 

Finally, there are some exceptional cases that merit attention. The individuals who suffer cognitive impairment, probably from sleep apnea, literally cannot observe the symptoms (e.g. dozing off) that others around them see quite frequently. Undoubtedly, you can only work with such patients when the “witness” plays a strong role in the patient’s daily affairs and can facilitate regular use of PAP. In time, the hoped for outcome emerges as the patient finally wakes up to the benefits. Sometimes the cognitive impairment improves as well, and then the patient fully takes hold of the reins. In related cases, patients suffering from depression may have considerable difficulty understanding the impact of their mental condition on their sleep problems. Ironically and sadly, depression appears to be a major risk factor for non-compliance with PAP therapy. Many of these patients will not succeed until the depression is effectively treated, which is rather frustrating for the patient and the doctor when it seems some of the depression may be attributable to sleep apnea. One last type of case, more common nowadays, is the pilot or truck driver who arrives at the center because of rules set by the FAA and DOT. Among this group, you could watch them dozing off in your waiting room while you glance at their recently completed Epworth Sleepiness Scale score of zero (no sleepiness whatsoever). These individuals have an agenda and many feel (appropriately so) put out by government intrusion into their livelihoods. Here, the circumstances may require automatic treatment following the diagnosis of sleep apnea, regardless of their symptom reports or even their negative results on daytime sleepiness tests.

Summing up, asymptomatic cases of objectively diagnosed sleep apnea reflect several different subtypes of patients, nearly all of which require more intensive evaluation and clinical follow-up. In many situations, you will see patients fail PAP initially and then return a year or more later to try again after a period of experiences or reflections leading them to recognize the necessity of treating their symptoms or in rare cases of preventing symptoms that have yet to arise.                                                                                

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

1 Comment


February 05, 2015

Hmm, now you got me thinking… hubby complains about my snoring and loud “camel snorts.” I MUST have my morning coffee. Sometimes I wake up in the middle of the night with a headache. And yet I don’t feel drowsy during the day, no problems with jet lag, and I always score low on those sleep apnea quizzes (2 points if you snore — and that’s it). Maybe I should get checked out?

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