Sleep Apnea from a Good Allopathic Perspective - My Overview from Local Seminar

I attended the local hospital's medical CEU (continuing education unit) this week titled "Obstructive Sleep Apnea Across the Specialties", presented by local physician David Patz.  I learned a lot from it and wanted to do a writeup about it and at least start the conversation and hopefully invite others who know about sleep and sleep apnea specifically to register as users and write here on Lumigrate.  As with anything lately, new research is stretching what the experts previously believed, and it appeared to me that many medical conditions have as a cause or contributor, sleep apnea.  Another case of 'which came first, the chicken or the egg?' 

Did you know that 'nocturia', more than two occurrences of needing to get up and void urine during the night and erectile dysfunction can be caused by sleep apnea? (refer to the journal Urology, 2008, 1;6:096-8).  Dilute morning urine osmolality in women patients with nocturia predicted OSA 88% of the time.  So then the question becomes 'is asking your physician to screen via morning urine osmolality' something that might make a lot of sense?  As you might see with Lumigrate, our concept is that YOU (the patient) in the most important place in the patient's health care team (the center) has a perfect position to bring information to their physicians -- it definitely applies to the patient the physician is doing their best to treat!  I put this information up high to catch the women who this information could help. 

Erectile Dysfunction -- I'm putting THIS statistic up top to catch the attention of the many men this information can help.  And naturally many women will read this and think of the men who this might be an issue for and be able to 'turn them on' to this as a possible contributor or cause (all puns intended).  In a study reported on my Reishtein in Journal of Clinical Sleep Medicine this year (2010, 6(3): 221-226) of men in intimate and sexual relationships, after utilizing CPAP machines the statistics are impressive, with difficulty in the following areas dropping as follows: Desire 69% to 40%, Intimacy 63% to 34%, Arousal 46 to 2% (yes, 2, I didn't forget a zero!), and Orgasm 29% to 18%.  These are really impressive statistics.  And considering the cost of Cialis, Viagra, etc., and how the cost and side effects of the medications if they can even be used by a patient, I'm likely going to put this in BOLD so people are sure to see it.  I know I have other write ups about hormones and cardiovascular health which relates to erectile dysfunction as well, and as I sat in this excellent allopathic seminar, I couldn't help but think about how ALL of it comes together.   I'll provide you with a link about that at the bottom. 

SO I was very pleased to get midway through the seminar and have a slide be about "Pituitary-Gonadal function in men with obstructive sleep apnea, effects of treatment", because naturally why take a hormone supplementally if you just need to be breathing, right?  Per Luboshitzky in Neuro Endocrinology Lett, 2003; Dec. 24(6) 463, leutinizing hormone and testosterone increased towards normal. 

Naturally, there is much attention in the United States and other modern countries, about diabetes, and obesity as part of the composite of diabetes and metabolic syndrome.  Leptin, which is a hormone that decreases hunger, was found to be affected by OSA, and about 50% of people with metabolic syndrome have a chance of having OSA, per a study by Punjabi et al.  One of the more significant pieces of information related to they hypothyroidism which was found related to OSA was that this was the case even without an increase in weight of the subject/person/patient.   Another study was Tamura in July 2008 in Res Med journal studying Japanese with sleep apnea; there was impaired glucose metabolism in 60% with AHI of 5 or more.  30% had abnormal glucose tolerance test and 30% had diabetes and the incidence increased when they looked at AHIs of moderate and higher. 

One of the advantages of getting to be middle aged is to have had the good fortune of knowing many people.  One special one in my past (and still a friend roaming around the country in retirement now) had surgery to correct sleep apnea .... because it was presumed the apnea was obstructive, and he was overweight to some extent, and he still had apnea!  Unfortunately, he wanted to play a musical instrument which ended up being limited by having had this surgery.  Eventually he took up drums and was pretty successful with them, playing in many bands.  But it's a case of what another friend of mine calls 'mangling medicine' -- if it's really necessary and the right thing, then these wonderful surgeries and gadgets are so amazing and wonderful, but when provided when not being appropriate, it is contributing to the mounting costs and frustrations of the people who are labeled as 'patients' or in our case here at lumigrate 'consumers'.   

I'm embarrassed to say I didn't think of this word myself which a friend shared this with me this week as he was utilizing Lumigrate eagerly related to information about lupus: "ConMed" (conventional medicine).  He said I could use it, and I'd like to use it only to make a point that many times people are provided information which almost unknowinly by the providers is so very 'tweeked' by the people who educate 'us'/them -- the drug companies and equipment manufacturing and vending companies which profit when their product is prescribed or done on a new patient/consumer.  

Obviously, it's critically important to treat sleep apnea, but when it's your specialty, I would certainly hope the providers run through a logical way of addressing the issues and don't START with the most invasive and expensive options.  So please think about this if you are a medical consumer, whether it be sleep apnea or acne. And I'm thinking about it as well, and will be approaching the integrative medicine team of acupuncturist, naturopathy, and integrative medicine MDs about it and asking them for their comments here, as well as allopathic providers because they're part of our health care system and as evidenced from this seminar, a wonderful resource to the majority of people in the system today.

In keeping with having Lumigrate's concept to be 'streamlined' (in that what you initially read is a brief overview which is also progressive and valid, with FUN being our overall site's intention, I'm not going to provide a ton of detail here but will work to have someone qualified to provide that detail provide that (perhaps Dr. Patz, I'll invite him, as I liked his presentation very much). 

Let me start with one of the more impressive statistics from the presentation:  85-90% of people with obstructive sleep apnea are undiagnosed. 

SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA
Excessive daytime sleepiness is the "hallmark symptom"
Snoring whether there are observed apneas or not
Morning headaches
Irritability, mood issues, depression
Attentional difficulties (think of this with children and young people)
Cognitive difficulties (think of this in older people in particular)

A very interesting study was done almost 20 years ago where all employees of the state of Wisconsin were screened, apparently between the ages of 30 and 60.  (Reported on in Young, T., et al., New England Journal of Medicine, 1993, 328: 1230-5).   "Mild" sleep apnea is considered 5-15 episodes per hour, "moderate" begins at 15 episodes.  They found that 24% of men had mild, 9% had moderate.  In women, 9% had mild and 4% moderate.  With 'mild', only 4% of men and 2% of women with mild apnea reported being 'sleepy'.

A quarter to a third of people who are found by sleep study to be appropriate for a CPAP machine are 'uncooperative' with having one.  (My note: One of the things I noticed when becoming an occupational therapist when I was in my mid 30s was the wording used.  Patients are 'uncompliant', 'complain', and my personal favorite learning curve was when my first patient on level 2 fieldwork had documentation in his chart saying he 'denied alcohol abuse' and I interpreted that to mean they though he wasn't telling the truth.  So, instead of saying 'would prefer not to use a CPAP machine' or 'refused', this presentation used the word 'uncooperative' which made me think about what other things might be options instead of CPAP for the high number of people who are appropriate for this important remediation.  Examples provided at this seminar are supplemental oxygen and surgery via an ENT specialist.

In an article by Al Lawati et al. (in Prog. in Cardiology, 2009, 51; 4:285-03), the incidence in the elderly (age 70 and over) is 21% had 15 or more episodes per hour.  Patients with high blood pressure had 38% and those with drug resistant high blood pressure 80%, and those evaluated before bariatric surgery was 71-77%. 

It is important for people to know if they have sleep apnea before having anesthesiology with surgery, as it affects what goes on throughout the intubation and extubation/recovery.   Per Gupta (Mayo Clin Proc 2001; 76:897-905), there were complications at a rate of 39% versus 18% and serious complications following knee and hip replacement surgeries in 24% of patients with obstructive sleep apnea.  So this is an example of how therapists such as physical therapists can be critical in the health education 'team' of any patient they are seeing who will be having a surgery, because they can be referring patients to this information.  (Naturally, hitting 'print' at the bottom of this page is one option we recommend). 

Obviously, as this seminar included, the anesthesiologists are important as the 'gatekeeper' to finding if someone has sleep apnea, but if anyone has the pleasure of interacting with them when having procedures, they are frequently scrambling around, juggling due to the changing demands of time of the surgery space. 

Narcotics and sedatives are particularly problematic for patients with sleep apnea, as they relax the muscles of the pharyngeal area and suppress CNS (central nervous system) response to the arousal signals of obstruction.  So it is recommended that physicians start including the STOP questionnaire in their intake and yearly physical paperwork.  S (Snore? yes/no), T (Tired in the day? yes/no), O (Observed apnea? (yes/no), Pressure of the blood is high? (yes/no).  If a person answers yes to 2 or more of the 4 questions, it is suggestive that obstructive sleep apnea may be a concern to be further investigated.

For information about STOP, refer to Chung, F, Anaesthesiology, 2008; 108(5): 812-821.  The precise wording of STOP is:
Do you snore loudly?
Do you often feel tired, fatigued or sleepy during the daytime?
Has anyone observed you stop breathing during your sleep?
Do you have, or are you being treated for high blood pressure?

Then there is BANG, and if you have three of these, it suggests OSApnea
Body mass index > 30
Age > 55
Neck circumference 17-1/2 inches or more
Gender = male

The evidence related to OSA and stroke and dementia is impressive as well, and it makes sense:  repeated hypoxic (low oxygen) events affects the blood vessels, so in cases of multi-infarct dementia.  In patients with Alzheimer's, three weeks of CPAP in patients with OSA improved memory, verbal learning and executive functions such as mental processing speed and cognitive flexibility.  Having a close family member with a dementia condition and an obvious and documented sleep disturbance I just find this a fascinating area that I hope gets much improvement in the future. 

Related to depression and insomnia: If a patient has depression where they primarily have fatigue or low energy or are not responding well to medications, sleep apnea should be considered.  If there are frequent arousals and awakenings at night as well. 

The International Diabetes Federation Task Force in their epidemiology and prevention focus have stated that health care professional working in clinics with either diabetics or those with sleep apnea patients should adopt clinical practices ensuring patients with one condition are screened for the other.  Which is great!  But let's make it GRATE, and pass this information on from person to person -- and consumer to provider as well --   most likely, everyone knows many people who have diabetes and sleep apnea, possibly some who aren't aware they do!  So think about who you know who has any of the things talked about here, such as those who might be up a lot due to frequent urination at night or who have erectile dysfunction, increased weight and related frustrations, and point them in the direction of this kind of information!  Again, PRINT or email this link to someone is one thing YOU can do.  Educating your providers is something you can do to help MANY people indirectly.  According to the number of people in the room for this presentation I attended, it's something of interest in the medical provider community and we can help support our providers by streamlining their education and pointing them toward good information I am fortunate enough to be able to attend and provider here at Lumigrate. 

So, in closing, the long list of things which can have sleep apnea as a contributor or cause are:
Atherosclerosis, coronary, cerebral, PVD (peripheral vascular disease),
Insomnia, fragmented sleep,
Depression,
Fatigue no energy,
Hypertension, essential or resistant to medication,
Heart failure or cardiomyopathy,
Atrial fibrillation or other arrhythmias,
Dementia,
Diabetes, metabolic syndrome,
Overweight,
Erectile dysfunction,
Nocturia,
Attention Deficit Disorder,
Failure to thrive in children,
Pregnancy,
Surgery, planned

How many of these have YOU had?  I've had TEN of these diagnosis documented in my medical records in the past, which means providers gave them to me, and never had any of my medical providers in the last 20 years since these medical problems started suggest a sleep study except to rule out seizures about 10 years ago when I was also having heart arrhythmias.  So as Maya Angelou says 'When you know better, you do better'.  I learned a lot from this information and just as Dr. Young's video (free at Lumigrate.com) discusses about the law of the lamp post, my 'hammer' now will hit in a different area thanks to this seminar's excellent information.  I'm glad it was well attended and now I hope we all do something to educate others too.

Link to information about biologically identical hormones and Heart Health (think of Erectile Dysfunction as a fortunate outward symptom men have which indicates cardiovascular health) related to a seminar by our local expert Scott Rollins (with links to his website which has LOTS of good information on it if you're interested in more.  I HIGHLY Suggest you take the time!).  www.lumigrate.com/blog/hormones-are-here [1]

Link to the Forum in our Fibromyalgia section by our current MD/Anti-aging MD expert, Marc Spurlock has written for Lumigrate about cognition and hormones, sleep and hormones, and other interesting information: www.lumigrate.com/forums/health-issuesdis-eases/fibromyalgia-chronic-pain-and-chronic-fatigueexhaustion/wm-marcus-spur [2]