What is Sleep Apnea?
The Importance of Sleep
Getting a good night’s sleep – it’s something we all want and need. Our outlook on life and daytime productivity depend on it. Our health is impacted by it. But when we don’t sleep well over time, it affects our lives in a big way. Dr. Michael Zupancic and the staff at The Sleep Center are committed to improving this important aspect of your life. From evaluation of your sleep, to diagnosis of your sleep disorder, to treatment options, and ongoing care, we want to work with you to make sure you have the opportunity for a good night’s sleep!
The Sleep Center consults with you regarding your particular sleep problems. Common sleep complaints include snoring, insomnia, non-refreshing sleep, day time sleepiness, morning headache, and restless leg syndrome. Often it is the bed-partner who notices you snore or are restless during sleep. Did you know that one of the most common sleep disorders, obstructive sleep apnea, increases your risk of hypertension, heart disease, and stroke? Sleepy drivers are at risk of car crashes. Productivity at work and home may suffer.
The Sleep Center conducts sleep studies administered by highly-trained technologists at our Carlsbad, California facility. The data gathered from the sleep studies is interpreted by our board-certified sleep medicine physician. We take this information and develop a personalized treatment plan in collaboration with you. We are committed to ongoing evaluation to make sure the treatment is effective and you are sleeping better. Appointments are available in Carlsbad and Escondido.
Sleep is important for both physical and mental health. More than 25% of Americans report problems with sleep or daytime alertness. People who suffer from disordered sleep report lower quality of life, impaired job performance, and have higher rates of mood disorders. Despite the negative consequences of sleep disorders most people remain untreated.
Insomnia is a common condition that is often undertreated. People with insomnia have problems falling and/or staying asleep which negatively affects how one feels and functions the following day. People suffering from insomnia often report difficulty concentrating, fatigue, emotional change, and impairment of performance. Those with this condition are more likely to miss work or familial commitments due to their disordered sleep. Most people with chronic insomnia feel frustrated at their inability to sleep.
Fortunately there is hope; chronic insomnia can be treated with a variety of medications or behavioral strategies. The first step to treat insomnia is to evaluate contributing causes of this condition. For instance, many people with restless leg syndrome have difficulty falling asleep due to uncomfortable sensations in their lower extremities which occur predominantly at night and delay sleep onset. People with Periodic Limb Movements of Sleep and Obstructive sleep apnea frequently have disrupted sleep with numerous awakenings overnight.
Psychophysiologic insomnia is a very common cause of chronic insomnia. People with this condition have developed maladaptive behaviors which perpetuate their insomnia. This chronic insomnia usually begins with a stressful life situation that causes difficulties falling and staying asleep. However, once this event has dissipated people with this condition still have problems with falling/staying asleep. Despite devoting more time towards sleep they remain awake which causes significant frustration, leading to cortical activation, which further impairs sleep. They do not look forward to going to bed at night and often ruminate about the negative consequences of sleep loss. Sleep specialists at the Neurology Center are very knowledgeable about non pharmacologic and pharmacologic treatments of this condition.
Obstructive Sleep Apnea
Obstructive sleep apnea is a common and underdiagnosed condition which negatively affects one’s health and well being. Approximately 10 % of men and 5% of women have OSA. OSA is caused by episodes of upper airway closure when asleep.
When we sleep at night all the muscles of the body relax. This includes the muscles of the upper airway. In susceptible individuals this can lead to upper airway narrowing & closure. Snoring is caused by vibration of the upper airway tissues when asleep. Snoring by itself is a cosmetic disorder that does not negatively affect ones health (though it may disrupt the sleep of ones bed partner!) Most people with OSA snore but not every one who snores has OSA.
In people with obstructive sleep apnea the airway muscles relax too much when asleep so that the airway becomes partially or completely blocked for several breaths. (Please see figure) As a result of the obstructed airway airflow to the lungs is reduced which decreases oxygen delivery to the bloodstream. When this occurs the brain arouses out of sleep as a protective mechanism. It sends strong signals to the airway muscles to open up, and a person resumes breathing normally. The person usually falls back asleep within several seconds unaware of the sleep disruption. However, this fragmentation of sleep leads to many of the daytime symptoms of OSA.
Nighttime symptoms include snoring, gasping, apneic episodes (pauses inbreathing) when asleep, frequent awakenings, restless sleep, nocturnal sweating, and needing to awaken frequently to urinate.
People who suffer from OSA often awakens un-refreshed in the morning. They often feel sleepy, tired, fatigued, or lack energy throughout the day. Untreated OSA can contribute mood disorders and certain headache conditions. People with untreated OSA are twice as likely to have automobile accidents due to mental tiredness and decreased attention when driving. Men who have untreated OSA are more likely to suffer from erectile dysfunction and treatment of OSA can improve this condition.
OSA health Complications
Untreated OSA can cause and worsen hypertension, an irregular heart rate such as atrial fibrillation, heart failure, coronary artery disease and stroke. Treatment of OSA has been shown to reduce the risk of developing these health conditions and often improves them if they exist. Treatment of OSA may improve glucose control in diabetics as well.
OSA Risk Factors
Risk factors for Obstructive Sleep Apnea include male gender, obesity, neck circumference over 17 inches in men, and advanced age. Woman who are post menopausal are twice as likely to develop OSA. Having a first degree relative with OSA doubles ones risk of having this condition. More than half of people who have suffered stroke have sleep apnea and it is estimated that approximately one half people with atrial fibrillation and/or heart failure have OSA.
There are several different treatment options of OSA. Weight loss can cure OSA in obese subjects. Avoiding alcohol and other sedative mediations is recommended as these relax the airway muscles and worsen the condition.
CPAP therapy is the most common and effective treatment in those with OSA. People who use CPAP therapy sleep with a mask that fits over their nose. This mask is attached to a hollow tube which is attached to an air pump that sits by the bedside. The air pump creates a constant positive airway pressure (CPAP) which is transmitted to the airway via the mask and keeps the airway open by acting like a pneumonic splint (see figure). CPAP treatment usually normalizes breathing at night and eliminates snoring. This therapy usually takes several weeks for the patient to become entirely adapted.
A mandibular advancing oral appliance, or MRD, is often a reasonable treatment in those with mild or moderate OSA. It works better in slender people. The MRD is a device, made by a dentist that one wears when sleeping. It attaches to the upper and lower teeth and protrudes the lower jaw forward. This action opens up the airway as the tongue is attached to the lower jaw. This treatment often improves sleep apnea and reduces snoring significantly.
There are several surgeries which can improve OSA. Studies have shown that in people with OSA and nasal obstruction, nasal surgery will improve OSA in 15% of subjects. Uvulopalalatophayngoplasy is a surgery preformed by an otolayngologist (or ENT doctor) where the part of the soft palate and tonsils are removed. Studies show this therapy improves OSA approximately 40% of the time. However, the long term results of this treatment are not as good as there is a high relapse rate of the sleep apnea.
Maxillo mandibular advancement is a very effective surgical procedure which can cure OSA. This surgery is preformed by an oral/facial surgeon. During this procedure the bones of the face and jaw are severed and advanced approximately 1 cm moving the tongue and soft palate forward. This procedure cures OSA in 85-90% of subjects but it takes approximately 1 month to completely recover.
Restless Leg Syndrome
Restless Leg Syndrome (RLS) is a common condition that is estimated to affects 10% of Americans. People with RLS report a strong urge to move their legs. They describe uncomfortable sensations typically occurring deep in their lower extremities. These feelings are temporarily relieved with movement. They can be burning, prickly, achy, or tingling. These sensations usually occur in the evening or night.
Though the sensations are usually not painful they are incredibly unpleasant and can interfere with ones ability to enjoy relaxing sedentary activities such as dining, watching TV, going to the theatre, or socializing with friends. Furthermore many people with RLS have difficulty sleeping due to their urge to move their legs. People with RLS often report tiredness and fatigue due to their poor sleep. They also are more likely to suffer from anxiety and depression.
Renal disease, pregnancy and iron deficiency can contribute to RLS. There are a variety of medical conditions which can mimic symptoms of RLS including vitamin deficiencies, spinal cord dysfunction, radiculopathies, and peripheral neuropathy.
Fortunately there are a variety of non habit forming medications which effectively treat RLS. For evaluation please contact the Neurology Center and request a consultation with one of our specialists.
Parasomnias are undesired behaviors which occur during sleep. There are two main classifications of parasomnias; REM parasomnias and NREM parasomnias.
REM Behavior Disorder
REM Behavior Disorder (RBD) is one of the most common parasomnias which occurs during REM (dream) sleep. It occurs more frequently occur in men over the age of 50. People with RBD act out their dreams and often yell when asleep which can result in injury to oneself or their bed partner. People who have this condition often describe their dreams having persecutory themes which are violent and intense.
Normally during REM sleep the only muscles which move are the eyes, tongue, and diaphragm (for breathing). BRD occurs because the brain’s control center which normally paralyzes the body during REM sleep does not work correctly. This condition is seen more frequently in people with Parkinson’s disease and certain types of dementia. People with untreated obstructive sleep apnea can have symptoms which mimic REM behavior disorder.
There are several medications that effectively treat RBD and prevent these behaviors from occurring. The most effective is Clonazepam which is a prescription medication taken before bedtime.
Sleep walking (Somnambulism) is one of the most common parasomnias. People with this condition get up out of bed and walk around but they are still asleep. The person’s eyes remain open but they often have a glassy stare. When sleepwalking a person might do activities that they would normally do during the day but more often they involve actions that are crude. For instance a person sleepwalking may urinate in a trash can or climb out a window. People can be violent when sleepwalking and can injure themselves or others. It is very difficult to awaken as sleep walker. Certain medical conditions, such as obstructive sleep apnea, increased the frequency of sleepwalking.
Sleep walking is more prevent during the first decade of life and affects up to 10% of children but often gradually diminishes until adulthood. Having a first degree relative who sleepwalks increases ones risk of developing this behavior. Untreated OSA can also increase the frequency of sleep walking. Certain sleeping pills can cause sleepwalking. Sleep deprivation, stress, alcohol consumption, and sleeping in an unfamiliar environment can also exacerbate sleepwalking. Frontal lobe seizures can sometimes be confused with sleepwalking.
Treatment of sleepwalking involves evaluating underlying or contributing causes to the condition, such as OSA. Avoidance of both alcohol and sleep deprivation is also recommended.
Behavioral strategies to reduce sleep walking include placing the mattress on the floor and sleeping in a sleeping bag. This makes it more difficult to leave the bed.
Home safety is very important if one sleepwalks. Ideally the bedroom should be on the first floor to minimize injury if one climbs out the window. Weapons and car keys should be locked away at night. An alarm or bell should be placed on the bedroom door to alert other family members about a potential sleep walking event. If one finds a room-mate who is sleepwalking it is best to gently lead them back to their bedroom to avoid injury.
If sleepwalking persists there are prescription medications which can reduce or eliminate these events.
A nightmare is a disturbing visual dream sequence that awakens one out of sleep. They usually illicit anxiety, terror, fear, sadness or disgust. When a person awakens from a nightmare they can usually fully recall the dream sequence which awoke them. They occur during Rapid Eye Movement (REM) sleep. Most people have experienced a nightmare.
Nightmare Disorder is a condition where one has recurrent nightmares which interfere with sleep. A person who has frequent nightmares may not look forward to going to sleep a night and may have difficulty returning to sleep after awakening from a nightmare. People with REM Behavior Disorder also have nightmares.
Certain medications can exacerbate nightmares such as propranolol. Treatment of nightmare therapy often includes image rehearsal therapy or behavioral strategies to reduce underlying stress. Certain medications can be used if nightmares persist.
Narcolepsy is a condition that causes excessive daytime sleepiness. This condition affects 1/2000 people. Symptoms of narcolepsy include daytime sleepiness and unwanted episodes of sleep, called sleep attacks. Sleep attacks can occur when active such as when talking, eating, or driving. Their sleepiness often negatively affects them both professionally and personally. Short naps, lasting 15 minutes, can improve narcoleptics alertness for several hours but severe tiredness returns. Most people with Narcolepsy suffer from the condition for more than a decade before they are correctly diagnosed and treated.
People with Narcolepsy also have dream like phenomenon that occur when awake. 2/3 of people with this condition have cataplexy, which is the abrupt loss of muscle tone precipitated by a strong emotion. Sleep paralysis (episodes of awakening paralyzed lasting 30 – 90 seconds) and hypogogic/hypnopompic hallucinations (hallucinations lasting several seconds to minutes when the brain is party awake and partly in dream sleep) are also common symptoms of this condition.
Narcolepsy is usually caused by an autoimmune process which destroys a small population of cells in the brain responsible for switching between the dream and wake states. Unfortunately there is no cure for narcolepsy. There are a variety of mediations which improve symptoms of this disorder and ones quality of life.