Sleep should be peaceful and restorative. But even after slipping blissfully to sleep, many Americans stay busy and stressed overnight — and most don’t even know it. But their spouses and partners sure do.
“There’s the stereotype of the light-sleeping wife just lying there listening to her snoring husband,” said sleep doctor Kimberly Hutchison of Oregon Health and Science University. Until she gives him the gentle or not-so-gentle elbow, that is.
Snoring may be a joke, a minor frustration or both. But it’s also a major indicator of sleep apnea, a condition that can have serious health effects if left untreated — which it usually is.
Sleep apnea means sleepers’ breathing is repeatedly interrupted throughout the night by their own relaxed throat muscles. Hutchison said the back of the throat is “collapsible, like a balloon, and when it gets closed off, you’re not getting any air.”
“When you lie down to relax and sleep at night, the back of the throat relaxes and the airway gets closed off,” she said.
The result can be dozens or even hundreds of interruptions of breathing per night. Each time, one’s oxygen level starts to drop until the brain notices and wakes up the sleeper with a jolt of fight-or-flight chemicals and raised blood pressure.
The sleeper may not wake all the way back to consciousness, just enough to snort and start breathing again, Hutchison said.
“You can certainly have no idea what’s going on,” she said. “Your partner might.”
You may start to realize it, though, if you keep waking up feeling unrefreshed after what seem like full nights of sleep. Unrefreshed in the morning can translate into moody, unfocused and fatigued during the day, Hutchison said. Feeling unusually sleepy — not just run-of-the-mill nappy but “really struggling,” Hutchison said — during daytime is a prime indicator of sleep apnea.
Those are the immediate results of sleep apnea, but it causes long-term risks too. The cumulative effect of dozens or even hundreds of apnea episodes per night for years or decades — each event raising blood pressure and delivering that cocktail of stress-response chemicals — can be profound. Heart disease, stroke, blood sugar irregularities, sexual dysfunction and even memory problems and dementia have been linked to sleep apnea.
Sleep apnea is thought to be fairly widespread in the U.S., but it’s also underknown and underdiagnosed, Hutchison said. The American Medical Association estimates that 30 million Americans actually have the commonest form of sleep apnea, but only 6 million have been diagnosed.
Diagnosis requires an overnight sleep study that’s sometimes in a lab but often done at home with a portable electronic device that records brain waves, heart rate, breathing, oxygen levels and muscle movement. Yes, this means sticking little sensors onto your face and wearing them overnight.
The study reveals exactly how many apnea episodes the sleeper experienced. Between five and 14 episodes per hour is considered mild sleep apnea; 15 to 29 is moderate; and 30 or more episodes per hour is considered severe sleep apnea.
Awareness and diagnoses are both growing fast these days, Hutchison said. That holds promise for sufferers but also risks of unproven, problematic treatments and interventions. It’s important to work with a doctor to assess your sleep apnea and to be skeptical of treatments that don’t have track records of success, she said.
Fortunately, she said, the most common treatment approaches are proven successful. First of all is weight loss. Sleep apnea is associated with being overweight (and being male and older), and an initial commonsense approach might include focusing on weight loss and better overall fitness.
“America has this obesity epidemic,” Hutchison said. “We are a heavier population now than we’ve ever been. Being overweight and snoring are the top risk factors for sleep apnea.”
While helpful with apnea (and overall health and wellness), losing weight is not usually considered a complete cure. Many patients strive for weight loss as they also seek more direct apnea treatments, Hutchison said.
Masks and fans
Today’s airway-pressure machines are worth a second look from anybody who’s ever eyeballed or tried one and found it a cumbersome and unrelaxing way to achieve a good night’s sleep, she said.
“It’s unfortunate that there’s this stereotype about CPAP machines,” she said. “I have witnessed this machine change so many lives. It’s been a game changer to get them the sleep they need.”
CPAP means continuous positive airway pressure. The sleeper wears a mask over mouth and nose — or, in some cases, just the nose — that delivers a gentle stream of air through a tube connected to a side-table device.
“The machines have improved,” Hutchison said. “They are smaller and quieter, and they look a lot less ‘medical.’ There are also a lot of different masks out there. Some are quite small and low-profile. It does take some commitment to figure out the right fit for you.”
While CPAP is widely described as the gold standard for sleep apnea treatment, not everybody adapts easily to sleeping with headgear. It’s widely reported that about 80 percent of users who stick with CPAP are happy with it, while as many as one-third or more of all starting CPAP users give up on it.
Hutchison said advances in CPAP and related technology are encouraging, including a flexible-silicone mouthguard product she’s developed called SomniSeal that improves the efficiency of nose-only CPAPs. Many people prefer a nose-only CPAP because it’s more comfortable and less claustrophobic than a whole face mask, but it doesn’t work for everyone.
The hot CPAP product on the market today that’s heavily advertised to older adults is tubeless and maskless and seems to promise it all. It’s called micro-CPAP, and it involves nose buds that contain tiny fans that blow air up your nose. That helps hold the throat open and doesn’t interfere with exhalation though the mouth, Hutchison said.
Critics point out that micro-CPAP has been on the market for years and still hasn’t won approval from the Food and Drug Administration as an effective apnea treatment.
“There is some promise that micro-CPAP may be helpful for milder sleep apnea,” Hutchison said. “But it hasn’t been proven.”
CPAP DIY
The primary alternative to CPAP is a mouth appliance that pulls the jaw forward just enough to clear the airway. A dentist trained in fashioning such appliances can provide you one that fits well, but it will cost $1,500 or more. For a fraction of that cost you can buy self-fitting “boil-and-bite” appliances at a pharmacy or online.
A professionally fitted one is almost certainly going to do a better job, Hutchison said. But a “boil-and-bite” appliance may be worth a try if your apnea is mild to moderate.
“Custom ones are more comfortable and durable,” she said, “but if you bought one online for $100 and find that it’s working, great.”
If you have a documented sleep apnea diagnosis, then your primary medical insurance (not your dental) may well cover the steep cost of a custom appliance, Hutchison said.
Tech and test
In this high-tech world, there are interactive devices that can train you to sleep on your side, which helps with apnea. (Some folks just attach tennis balls to the backs of their jammies.) There are even surgeries and implantable devices for sleep apnea.
Inspire is device surgically implanted in the neck and chest that stimulates the airway to keep it open. You can switch it off during the day and on at night. Inspire has been approved by the FDA and works well for some people whose severe apnea hasn’t been helped by CPAP, Hutchison said.
The approach may work, but Hutchison dislikes Inspire’s marketing, which seems to involve “CPAP shaming,” she said. She’s afraid the gung-ho company leaves it up to doctors to explain the realities and potential complications of living with an implanted device, she said.
“It’s an extreme option, because part of it will be inside you forever,” she said.
No matter what route you take, Hutchison said, it’s important to stay skeptical and verify results with credible sleep study data. Be skeptical of phone or watch apps that claim to track your snoring, your breathing, even your oxygen level, Hutchison said.
“There’s a new thing coming out every few months,” she said. “You want to have a very validated form of measuring and monitoring. At this point in time, that would be your physician.”
