Dream on: Treating a sleepy situation

Nights riddled with sudden starts and stops. Days marked by bouts of nods and yawns. Inappropriate daytime dozing. Labels like sleepy and lazy.

For many people with sleep apnea, these characteristics are a part of daily life, not "symptoms" or difficulties, until someone else pushes the issue.

There's a classic scenario, says Kevin Gleeson, MD, professor of medicine at Pennsylvania State University College of Medicine. A husband and wife come for an appointment. "I ask the man, 'What brings you here?' He looks at his spouse. 'I don't have a problem, she's the one with the problem,' " says Dr. Gleeson. "They don't know they snore, they don't know they are sleepy during the day." And he can point to about 4,000 or 5,000 similar tales.

Because of such denial, Dr. Gleeson says, he's got a drawer full of snoring tapes. "The wives frequently bring in an audiotape of their husband snoring. They feel they need to testify that the snoring is present."

Sleep apnea is increasingly on physician radar screens. And recognition of this insidious and potentially life-threatening condition by family doctors has increased nearly twelvefold in the past decade, says Robert Ballard, MD, a pulmonologist and director of the Sleep Center at National Jewish Medical and Research Center, Denver.

Still, there's room for improvement. An estimated 80% of people with sleep apnea remain undiagnosed.

There are multiple reasons: The person has no idea it is happening; doctors often fail to ask the right questions about sleep; and cultural mores suggest that sleep is unimportant or even a sign of weakness.

"We pride ourselves as a country that we don't need any sleep," says Peter D. Waite, MD, DDS, MPH, professor and chair of the Dept. of Oral and Maxillofacial Surgery, University of Alabama School of Medicine. "Culturally we are all sleep-deprived."

According to estimates, nearly 18 million Americans have sleep apnea. Commonly associated with overweight, middle-aged men, sleep apnea actually affects people from all walks of life -- young men of average weight and women and children as well.

There are two types of apnea: central, in which the brain fails to send appropriate signals to the breathing muscles to initiate respiration; and obstructive, the latter being much more common. In obstructive sleep apnea, air cannot flow into or out of the mouth or nose, although efforts to breathe continue. Airway blocks can occur because of structural or mechanical problems, excess tissue in the airway, or relaxing of the throat muscles and tongue during sleep.

While it's rare to die of the condition, the long-term effects of repeated apnea and arousal shorten life expectancy, says Dr. Waite. It's been long recognized that apnea affects cognitive function, and researchers are starting to accumulate evidence that it's important to treat the condition early because it appears to be also associated with high blood pressure and cardiovascular problems.

"I think primary care physicians are in a unique role to educate themselves and the public about the importance of sleep. There is no substitute for a good night's sleep," says Beth Malow, MD, associate professor of neurology at Vanderbilt University Medical Center in Nashville, Tenn. She recalls her days as a resident. "After 36 hours I was edgy, irritable, cranky, negative. It's up to us as doctors to get the message out."

What is sleepiness?

To stem its progression, patients with sleep apnea risks -- men, especially those 40 and older; postmenopausal women; and patients who have high blood pressure, heartburn or central obesity, or who have had witnessed lapses of breathing or loud and frequent snoring -- should be asked about their sleep habits. It takes about three minutes, says Dr. Malow. Use simple prompts: Tell me about your sleep. What time do you go to bed? What time do you wake up? Do you snore loudly? Are you sleepy during the day?

Nonetheless, the enigmatic nature of snoring and sleepiness makes getting to the crux of what's going on more challenging.

"Sometimes it's hard to get from patients how good or bad their sleep is," says Anne H. Remmes, MD, assistant professor of neurology, the Neurological Institute of New York at Columbia University. "People don't recognize that they are sleepy during the day. One of our roles is to get people to begin to recognize when they are sleepy."

When a patient says they don't snore, ask the partner, says Dr. Gleeson. "If a man comes in by himself and denies snoring, I ask if his wife is still sleeping in the same room. About half are not." While about 95% of people with sleep apnea snore, all people who snore do not have sleep apnea. "If they snore and don't have daytime sleepiness," says Dr. Gleeson. "I say fine, then drop it."

So how is sleepiness determined? Dr. Gleeson suggests asking questions that involve a scenario, like this one: When you get home from work, make dinner and get the kids to bed, then what do you do? Most say they watch TV. But then ask what happens next.

Other questions might be: Do you ever fall asleep during the day when you don't want to? While driving? At work? During a meeting? At a traffic light? When you relax at the beauty shop, in a waiting room or while reading, do you fall asleep? How many times might this happen in a day? How much alcohol do you drink in a day? Do you take any medications before bed? What is your sleeping position?

Some suggest patients keep a sleep diary.

An oral physical exam might reveal crowding in the space behind the tongue -- enlarged tonsils, large tongue, low or heavy soft palette, a long jaw or recessed chin -- or the area might look red and the nasal airway blocked, Dr. Remmes says. But, she adds, some patients have normal throats and still have serious sleep problems. "Then send them to a specialist to rule out sleep apnea."

Screening to sleeping

Sometimes screening is the hardest part. Diagnosis and treatment are relatively simple because patients feel so much better.

"It changes their life completely," says Steven H. Feinsilver, MD, chief of pulmonary medicine and critical care at North Shore University Hospital, Manhasset, N.Y. "Imagine if you only slept three hours a night, then eight hours. ... My sleep patients are my most gratifying."

Initially, sleep specialists recommend polysomnography, the gold standard for diagnosing sleep apnea in adults and children. The study, completed overnight, often in a sleep lab by a team of specialists, evaluates brain waves, REM sleep, breathing, body movements, heartbeats. "There is clearly a spectrum from mild to life-threatening," says Dr. Feinsilver. "We go over the sleep study and then decide on a treatment."

Occasionally mild sleep apnea can be treated simply with weight loss and behavior therapy like stopping smoking, and avoiding alcohol, sleeping pills and side sleeping. But most often physicians recommend nasal continuous positive airway pressure because it is currently the most effective treatment. But because the patient must wear a mask attached to a machine during sleep, compliance is an issue. "It's really off-putting," says Dr. Remmes. "And compliance is terrible. If the apnea is not severe I try to do other things."

That's why Hrayr Attarian, MD, a neurologist at the University of Vermont Regional Sleep Center in Burlington has patients use CPAP while staying overnight for the sleep study. "The sooner you start CPAP, the better," he says. "They feel so much better the next morning, they want to keep using it."

Although some medications have been tried as a treatment for sleep apnea, they haven't been found effective.

Some doctors swear by oral appliances or surgical options, but these are mildly effective, working only for some patients. Some appliances create a three-dimensional space in the back of the throat or bring the lower jaw forward to open the airway. "The appliance is more portable," says Ngozi Etufugh, DDS, an oral and maxillofacial surgeon in Manhattan. "And I find patients are more compliant than with CPAP."

Currently, researchers have developed several experimental treatments for sleep apnea, including radio frequency volumetric reduction of the tongue, which involves piercing the tongue, throat or soft palate with an electrode connected to a radio frequency generator. The inner tissue is then heated to 158 to 176 degrees, in a procedure that takes approximately half an hour. The inner tissues shrink, but the outer tissues, which may contain such things as taste buds, are left intact.

"There are devices that researchers are working on," says Dr. Attarian. "One is a signal that stimulates the throat muscles," he says. "But there are still problems with it."

"The bottom line," says Dr. Gleeson, "for us lung doctors, it is very gratifying to be able to participate in turning lives around.

"The key thing for primary care physicians to remember is sleepiness is a symptom that is not inherently abnormal, but the conditions that produce it might be. Don't ask if they are sleepy, but reproduce a situation when they are relaxed or bored and fall asleep. These behaviors might define the presence of sleep apnea."