Obstructive sleep apnea (OSA) is a serious medical disorder because of its direct impact on the brain and on the cardiovascular system. The direct damage caused by OSA stems from two highly disruptive factors seen in varying degrees in all patients suffering sleep-disordered breathing.
The first and most obvious are the changes in oxygenation that emerge as either desaturations or as fluctuations. Desaturations are the most widely reported, because of the clear-cut damage from repetitively dropping oxygen levels below 90% (normal) and the going back and forth, that is, above and below 90% every minute or shorter. Fluctuations are more subtle where the oxygen baseline fluctuates all night, again going up and down while remaining above 90%. Yet, both these oxygenation problems have been linked in humans or animals to brain damage.
The second factor, known as sleep fragmentation, is less widely reported and discussed, yet it probably has the greatest impact on the largest proportion of OSA patients. Sleep fragmentation literally means the quality of sleep is broken up into smaller bits and pieces instead of what we see in normal sleep where segments of 30 or 60 minutes or even hours on end of relatively uninterrupted sleep may occur. This fracturing of sleep is also thought to cause brain damage, and its cardinal sign of such is the daytime sleepiness that occurs after just one night of broken sleep due to OSA. Unfortunately, patients suffering from OSA experience the disruption night after night, and over time it is readily apparent these individuals are receiving far less hours of sleep than the actual amount of time they believe they are sleeping. Indeed, a severe OSA patient who believes he is sleeping 8 hours may in fact only be receiving 4 to 5 hours, and making matters worse these 4 to 5 hours are typically not the normal deep and restorative sleep. Rather, the sleep is often lighter and less refreshing.
With this backdrop on OSA, it should be readily apparently that these problems of gross sleep fragmentation and severe disruption to the oxygenation cycle would yield a cascade of abnormalities to human health, both physical and mental health. In the list below, you will see a number of problems or conditions that frequently arise in OSA patients. To provide a useful framework on how these problems are understood and dealt with by medical professionals, two lists will be offered, the first recognizing those problem medical professionals currently attend to; whereas the second list will describe areas in which most medical professionals demonstrate limited awareness:
Commonly Appreciated Facts & Pearls about OSA
- OSA is extremely common in adult men and may affect 25% or more of this population.
- OSA is extremely common among adults with essential hypertension, and its treatment frequently leads to better blood pressure control and sometimes outright elimination of any prescription medications for this cardiovascular condition.
- OSA is linked to pulmonary hypertension, coronary artery disease, cerebrovascular disease, cardiac arrhythmias, ischemic stroke, and untreated OSA also worsens congestive heart failure.
- OSA-related sleepiness is widely believed to factor into an enormous number of traffic and workplace accidents, including some of the recent disasters described world-wide involving trains, shipping, and possibly nuclear sites.
- OSA is thought to be the leading cause of nonrestorative sleep and therefore a leading cause of daytime fatigue or sleepiness, albeit many medical professionals are more likely to ask their patients first “how many hours of sleep are you getting?” before asking “how refreshing is your sleep?” The latter question is the classic way to assess the restorative nature of sleep quality.
- OSA is extremely common in patients with severe problems with obesity.
- OSA patients frequently suffer from chronic rhinosinusitis, and this nasal congestion often interferes with a patient’s efforts to use PAP therapy.
- OSA aggravates problems of erectile dysfunction and diminishes libido, and now current workups for these conditions often include overnight sleep testing.
- OSA through the process of sleep fragmentation is a major cause of cognitive impairment, adversely affecting memory, attention, and concentration and may actually be a precursor or risk for subsequent problems with dementia.
- OSA is a leading cause of post-operative complications and is now routinely assessed by surgeons and anesthesiologists during the pre-operation planning stages for any surgery requiring general anesthesia.
- OSA is very common in families. Even if just one parent suffers from OSA, all children in the family may be at risk, particularly the children with facial similarities to the parent with OSA.
Limited Appreciation of Facts & Pearls about OSA
- OSA is common in women, not just peri-menopausal and post-menopausal women.
- OSA is occasional to frequent in the 3rd trimester of pregnancy and may lead to various complications such as pre-eclampsia if left untreated.
- OSA is a leading cause of nocturia (trips to the bathroom at night) due its impact on the cardiovascular system, yet most patients with nocturia are not referred to sleep centers for evaluation.
- OSA is extremely common in chronic insomnia and has proven to be a major factor in causing this condition, previously thought to be strictly a psychological phenomenon.
- Treatment of OSA in chronic insomniacs may lead to anywhere from a 50% to 100% improvement in bouts of night time sleeplessness, particularly those episodes occurring in the middle of the night where PAP treatment has the most successful outcomes.
- OSA is very common in two mental health disorders, depression and posttraumatic stress disorder (PTSD), and there is early evidence that both disorders improve when the OSA is successfully treated.
- OSA is a leading trigger for napping behavior and excess consumption of caffeinated beverages.
- OSA is a major factor in triggering problems such as nightmares or other disruptive nocturnal sleep behaviors like sleepwalking or acting out dreams (while sleeping).
- OSA is arguably the leading cause of morning headaches.
- OSA shows preliminary evidence for being a risk factor for suicidal ideation and behavior, but only anecdotal evidence is available to show that treatment of OSA decreases these mental health symptoms.
- OSA has been conclusively linked to fibromyalgia syndrome (FMS) and is thought to aggravate other chronic pain conditions. Treatment of OSA has been proven to decrease FMS symptoms.
- OSA can easily be misdiagnosed as depression, because both conditions frequently present with the following symptoms: low energy, low motivation, anxiety, worry, irritability, sluggishness and weight gain.
As you see, there are innumerable connections between OSA and poor health conditions, both mental and physical. That so many of these connections are currently known among medical professionals is a positive step, but the long list on limited awareness shows much more progress is still needed.
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.
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