October 16, 2014 by Steven Park
One of the most common complaints by my patients with obstructive sleep apnea (OSA) is memory loss. Judith is a 55 year old woman who used to have a sharp memory, but now is having trouble with names and losing her keys all the time. Things got much worse when she gained more weight, which worsened her snoring. She was eventually placed on CPAP for her moderate obstructive sleep apnea, and is now happy to report that while her memory is not back to normal, it is much improved.
At a recent Airway Dentistry conference I went to last month, the most memorable topic was given by Dr. Ronald Harper, Distinguished Professor of Neurobiology at the David Geffen School of Medicine at UCLA. I’ve been following his work over many years, but his presentation only confirmed my suspicion that there can be significant brain damage with untreated obstructive sleep apnea. Based on various high-tech MRI technology, specific known areas of the brain can be damaged with repeated episodes of apneas and low oxygen levels. Note that the word “damage” can mean low functioning, or dead brain cells. Here are 5 particular areas of brain damage from untreated obstructive sleep apnea with their specific symptoms:
1. The right insular cortex. This is the area of the brain that regulates sympathetic control of the autonomic nervous system. If the insular cortex is damaged, baroreflex control is affected. The insula also controls nerve endings that relate to pain. Both OSA and sleep apnea patients are found to have insular cortex injury.
2. The vetrolateral medulla (VLM). This area of the brain controls breathing and blood pressure regulation. Injury to this area blunts and delays heart rate responses to sudden pressure changes. One sided VLM injury leads to an asymmetric response to blood pressure challenge, which can potentially cause heart rhythm problems.
3. The cerebellum is the area of the brain that helps adjust blood pressure control and motor coordination, including breathing. Damage to this area prevents the ability to coordinate vascular and motor activity.
4. The hippocampus is found to be significantly smaller in people with obstructive sleep apnea. This area of the brain processes short and long-term memory and spatial navigation. One study found that hippocampal damage can be partially reversed after a period of CPAP. The hippocampus is also one of the first areas to be damaged in Alzheimer’s disease.
5. Mammary bodies are important for memory recall, as well as for memory for certain smells. These structures are much smaller in patients with OSA, and almost nonexistent in patients with heart failure. The hippocampus and mammary bodies are also found to be damaged in chronic alcoholism.
If OSA can damage critical areas of the brain that regulates breathing, balance, memory, and the autonomic nervous system, the implications are enormous. For example, heart failure is thought to lead to central sleep apnea. Is it possible that untreated obstructive sleep apnea can damage breathing and reflex centers in the brain that can lead to heart failure? What proportion of Alzheimer’s disease is actually undiagnosed OSA? The possibilities are endless. As they say at the end of every scientific journal article, more studies are needed.
If you have both OSA and memory problems, did your memory improve at all after being treated? Please tell your story below.
(Take a look at the references below to take a look at the various photos and figures. The figure above is from the Macey 2002 paper)
Canessa, N., Castronovo, V., Cappa, S. F., Aloia, M. S., Marelli, S., Falini, A., et al. (2011). Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function before and after Treatment. American Journal of Respiratory and Critical Care Medicine, 183(10), 1419–1426
Henderson, L. A., Woo, M. A., Macey, P. M., Macey, K. E., Frysinger, R. C., Alger, J. R., et al. (2003). Neural responses during Valsalva maneuvers in obstructive sleep apnea syndrome. Journal of Applied Physiology (Bethesda, Md. : 1985), 94(3), 1063–1074.
Kumar, R., Chavez, A. S., Macey, P. M., Woo, M. A., Yan-Go, F. L., & Harper, R. M. (2012). Altered global and regional brain mean diffusivity in patients with obstructive sleep apnea. Journal of Neuroscience Research, 90(10), 2043–2052.
Macey, P. M., Henderson, L. A., Macey, K. E., Alger, J. R., Frysinger, R. C., Woo, M. A., et al. (2002). Brain Morphology Associated with Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 166(10), 1382–1387.
Macey, P. M., Kumar, R., Woo, M. A., Valladares, E. M., Yan-Go, F. L., & Harper, R. M. (2008). Brain structural changes in obstructive sleep apnea. Sleep, 31(7), 967–977.
Lal, C., Strange, C., & Bachman, D. (2012). Neurocognitive impairment in obstructive sleep apnea. CHEST Journal, 141(6), 1601–1610.
October 7, 2014 by Steven Park
Over the years, I’ve witnessed countless stories about patients with obstructive sleep apnea who undergo nightmare experiences while undergoing treatment. Oftentimes, the insurance issues can be worse than any medical issues. In his book, The Midnight Stranglers: A Personal Quest For Healthcare Transparency, Aiden Hill chronicles his painful journey from first being diagnosed with obstructive sleep apnea to his ordeal as a consultant helping California residents obtain health care coverage.
- Basic concepts of obstructive sleep apnea and consequence of non-treatment are covered. It’s not taken to be medical advice, but is well-written from a lay-person’s perspective.
- He describes the current flawed state of affairs with our health care system, likening it to Dr. Jekyll and Mr. Hyde. There can be a dark consequence to any good intention.
- With ongoing changes to our health care system, he emphasizes the importance of taking a pro-active approach before undergoing any type of treatment. Even then, you’re likely to get hit with an unexpected bill, despite putting in your due diligence. Expect to spend hours, days or even years dealing with the aftermath. I’ve experienced this personally numerous times.
- The problems that he encountered with insurances companies, doctors, hospitals, and government entities are all governed by the basic rule: “Protect the asset.”
- I completely agree that full financial transparency is needed before undergoing any medical transaction.
October 3, 2014 by Steven Park
When I first wrote my book, Sleep, Interrupted in 2008, I had a question mark in my diagram linking obstructive sleep apnea to possible cancer. Since that time, there have been a number of studies making that link stronger, and I am now more comfortable in removing that question mark. One of the basic hallmarks of obstructive sleep apnea is repeated episodes of low oxygen levels (intermittent hypoxia) due to obstructed breathing at night. If you google “intermittent hypoxia and cancer” you’ll see about 460,000 search results, of which 33,000 are scholarly articles. Low oxygen levels are strongly associated with cancer progression.
In a recent review article on this subject, Dr. David Gozal and colleagues published a paper titled, Sleep apnea awakens cancer: A unifying immunological hypothesis. They hypothesized that intermittent hypoxia and sleep fragmentation can promote changes in the tumor microenvironment, leading to a weakened immune system and tumor growth enhancement.
It’s important to remember that intermittent hypoxia not only can enhance cancer development, it can also in theory enhance benign tumor growth as well. One of many possible explanation is the concept of increased levels of vascular endothelial growth factor, which enhances more blood vessel growth, so that more nutrients (via blood) can reach the oxygen starved tissues. Initially, it may only cause localized enlargement of the soft tissues. Imagine if you continue to have intermittent hypoxia, and let’s say that you have a gene that makes you more susceptible to cancer. If you add additional lifestyle habits such as smoking and drinking alcohol, then one mutation can potentially lead cancer.
To date there hasn’t been any particular cancer that’s strongly associated with obstructive sleep apnea. However, one large-scale population study found that your chances of dying from cancer increases almost 5 times if you have untreated severe obstructive sleep apnea. Another study found a 2.5 times increased risk of having cancer and 3.4 times higher risk of dying from cancer with untreated moderate to severe obstructive sleep apnea.
Notice that the most common types of cancer happen in the “low priority” organs when you’re under stress. These areas include the gastrointestinal system, the reproductive organs, hands, feet, and the skin. In general, the core, central areas take priority. Any form of physiologic or emotional stress diverts blood flow and nervous system activation away from low priority to high priority areas. Rarely do you hear about cancer in the brain, heart or muscles, which are considered high priority.
This is another example of how sleep connects the dots between almost every known chronic health condition. Unfortunately, cutting edge cancer research focuses mainly on the molecular, genetic, and biochemical aspects without looking at the big picture. Without addressing proper sleep and breathing, even the best cancer treatments can give possibly suboptimal results.
If you have a diagnosis of obstructive sleep apnea, do you have a cancer history in your family?
September 24, 2014 by Steven Park
Oftentimes, I recommend a referral to a dentist to treat obstructive sleep apnea. Most patients will ask me, “How is a dentist going to help me?” My answer is that since obstructive sleep apnea is mainly a problem from small jaws and crooked teeth, they have a variety of different ways of helping you to breathe better and sleep better.
I just came back from presenting at an Airway Dentistry conference in Laguna Hills, CA. It was definitely one of the most exciting and rewarding conferences I have ever attended. All the speakers and the attendees are at the forefront of not only potentially better treatment, but also better prevention of obstructive sleep apnea.
The most common way dentists can treat obstructive sleep apnea is by making a retainer-like appliance that pulls your lower jaw forward. Since the muscle that attaches the base of your tongue connects to the lower jaw, moving the jaw forward will pull the tongue forward. This option works well for most people and is usually better tolerated than CPAP. However, because it’s a device that sits in your mouth, protruding your lower jaw, it can sometimes cause problems like profuse salivation, jaw pain and shifting teeth. It uses the upper teeth as a lever to pull the lower teeth forward, so the upper teeth can shift back to various degrees. Fortunately, this is unusual, and can be adjusted for by your dentist. In many cases, people don’t mind because sleep is so much improved.
Now there are a newer generations of dental appliances that work not by pulling forward your lower jaw, but by expanding your jaw wider and more forward, all without surgery. Granted, it can take much more time, similar to braces. However, it’s different from braces in that rather just straightening teeth, the entire jaw structure is significantly expanded, opening up the airway.
The downside to these newer options is that because they are so new, not too many dentists know about it, and it’s not generally covered by insurance. It’s also important to remember that there hasn’t been large-scale studies on obstructive sleep apnea treatment effectiveness. Hopefully, studies will be forthcoming. Currently, most dental appliances that are FDA approved for obstructive sleep apnea are the advancement devices.
Up to date dentists are also incorporating orofacial myologists who train your tongue and throat muscles properly. Since your tongue is your most important orthodontic appliance, how it’s used (along with the lips and throat muscle) can have a profound effect on the eventual size of your jaws and your upper airway.
I challenge everyone reading this post to find out how much they know your dentist knows about obstructive sleep apnea. Does he or she appreciate how important the teeth are in relation to your upper airway? Does your orthodontist still remove teeth before applying braces for your child? If not, at the risk of possibly offending your dentist, please direct them to the American Academy of Physiologic Medicine and Dentistry, and the American Academy of Dental Sleep Medicine.
What has your experience been with your dentist? How well are they versed in the importance of the airway?
September 17, 2014 by Steven Park
Many women look forward to a radiant, flawless glow that’s expected to come with pregnancy. However, despite the upbeat exterior, many pregnant women suffer from depression, with potentially serious medical consequences for the mother and the baby.
This paper reviews outcomes of pregnancy when mothers have depression. What they found was that having depression during pregnancy is significantly associated with higher rates of pre-term delivery, low birth weights, pre-eclampsia, and spontaneous abortion. In children born to depressed mothers, higher rates of emotional and behavioral problems were seen.
The prevailing theory is that increased stress hormones can potentially cause complications in the mother and the baby. However, it’s interesting that these same complications are very similar to complications of untreated obstructive sleep apnea. We know that poor breathing during sleep (which leads to inefficient sleep) can lead to increased levels of physiologic stress. Added weight gain and snoring are known and normal consequence of pregnancy.
With about 20 to 30% of pregnant women suffering from depression, it’s important to screen for depression. Better yet, perhaps doctors should routinely screen for obstructive sleep apnea in all pregnant women. Of course this paper doesn’t discuss depression that can happen after delivery (postpartum depression).
For the mothers that are reading this, did you suffer from depression during pregnancy, and if so, do you currently snore?
August 28, 2014 by Steven Park
Podcast #002 Show Notes
Reader Question: Do those anti-snoring devices that you see advertised really work?
Sleep Tip of the Day: How to minimize light pollution in your bedroom.
Resources mentioned in podcast:
Finding Connor Deegan video
American Academy of Physiologic Medicine & Dentistry (AAPMD.org)
Ride of the Zombies Charity Bike Ride
Subscribe in iTunes @ doctorstevenpark.com/itunes. Thanks for reviewing my podcast and rating me.
Listen to the MP3 file here. (Right click to download)
August 26, 2014 by Steven Park
You may be sick of hearing about ADHD (attention deficit hyperactivity disorder) in children, but it’s a real problem with potentially devastating consequences. Here’s an article I wrote for Respiratory Care & Sleep Medicine on how poor sleep is often neglected when diagnosing and treating ADHD. Stay tuned for an upcoming podcast interview with Ms. Valerie Deegan, who helped to create a moving video about her son’s severe ADHD.
August 20, 2014 by Steven Park
In the wake of Robin Williams’ untimely death by suicide, I think it’s appropriate to talk about the pink elephant in the room that no one seems to notice. Mr. Williams was known to suffer from severe depression, and there are reports that he also had early stages of Parkinson’s Disease. He also battled alcohol addiction.
It’s estimated that about 20 million people suffer from depression. It’s a consensus that depression is caused by a multitude of various factors, with a number of different brain biochemical and structural abnormalities.
Here are 7 known facts about depression, insomnia and obstructive sleep apnea:
1. We know that depression and insomnia and other sleep problems tend to go hand in hand. People with insomnia are found to have a ten-fold increased risk of developing depression later in life.(1) Treating insomnia in patients with depression resulting in almost double the rate of depression remission.(2) Another study found that the presence of depression and insomnia predicted a higher rate of obstructive sleep apnea.(3)
2. The hippocampus is one area in the brain (amongst many other areas) that is found to be smaller in people with depression.(4) This area controls long-term memory and recollection. Interestingly, this is the same area that is also found to be significantly diminished in patients with severe obstructive sleep apnea.
3. Men and women who reported stopping breathing during sleep more than five times per week were 3 times more likely to show signs of major depression. Numerous studies show a strong bi-directional link between obstructive sleep apnea and depression.
4. Patients with severe insomnia who don’t respond to prescription sleep aids have about a 75% chance of having undiagnosed obstructive sleep apnea.(5)
5. In people with obstructive sleep apnea and depression, CPAP resulted in significant improvements in depression scores.(6)
6. Obstructive sleep apnea is known to significantly raise your risk of heart disease. (Mr. Williams underwent open heart surgery in 2009).
7. Many people with obstructive sleep apnea compensate for fatigue by intense physical exercise. (Mr. Williams was an avid cyclist).
There’s now lots more research on the ravaging effects of obstructive sleep apnea and oxygen deprivation on various areas of the brain, including the pre-frontal cortex, hippocampus, and the thalamus. Not only is the brain deprived of vital blood flow and oxygen, but brain tissue density and volume are also found to be smaller. One small shining light amongst all the bad news is that the hippocampus can regenerate to some degree with improved cognitive abilities after many months of CPAP use.(7)
Granted, you could argue that depression can lead to obstructive sleep apnea, since lower levels of activity can lead to weight gain. But then poor sleep quality can lead to low energy levels and lack of motivation to do anything, Poor sleep is also known to cause weight gain. Certain antidepressant medications are also known to cause significant weight gain, which can also aggravate this vicious cycle.
In addition, many people with insomnia or obstructive sleep apnea use alcohol as a sedative to fall asleep at night. However, because alcohol relaxes your throat’s muscles, more apneas can occur.
In my practice, whenever I see anyone with clinically significant depression requiring medication, in the vast majority of cases, the upper airway is very narrow. Typically, they can’t sleep on their backs, and one or both parents snore heavily. They are never able to wake up refreshed.
All this is speculation, since no one has examined Mr. Williams for obstructive sleep apnea. But statistically speaking, given all of the above, and boing in his age group, he has a relatively high chance of having had untreated obstructive sleep apnea.
If you are diagnosed with depression and obstructive sleep apnea, which came first—depression or sleep apnea?
1. Ong, Jason C., et al. “Frequency and predictors of obstructive sleep apnea among individuals with major depressive disorder and insomnia.” Journal of psychosomatic research 67.2 (2009): 135-141.
2. Manber R; Edinger JD; Gress JL; San Pedro-Salcedo MG; Kuo TF; Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. SLEEP 2008;31(4):489-495.Taylor, Daniel J., et al. “Epidemiology of insomnia, depression, and anxiety.” SLEEP. 28.11 (2005): 1457.
3. Wheaton, Anne G., et al. “Sleep disordered breathing and depression among US adults: National Health and Nutrition Examination Survey, 2005-2008.”Sleep 35.4 (2012): 461.
5. Krakow, Barry, Victor A. Ulibarri, and Edward A. Romero. “Patients with treatment-resistant insomnia taking nightly prescription medications for sleep: a retrospective assessment of diagnostic and treatment variables.” Primary care companion to the Journal of clinical psychiatry 12.4 (2010).
6. Schwartz DJ; Karatinos G. For individuals with obstructive sleep apnea, institution of cpap therapy is associated with an amelioration of symptoms of depression which is sustained long term. J Clin Sleep Med 2007;3(6):631-635.
7. Canessa, Nicola, et al. “Obstructive sleep apnea: brain structural changes and neurocognitive function before and after treatment.” American journal of respiratory and critical care medicine 183.10 (2011): 1419-1426.
August 13, 2014 by Steven Park
One of the most common complaints that I hear about is that you keep waking up at night during sleep. Even if you don’t consciously “wake up,” the sleep study hypnogram (a graphic summary of your sleep stages) shows that your sleep is interrupted 10 to 20 times every hour by obstructed breathing, snoring, leg movements, and even teeth grinding. Frequent, interrupted sleep can lead to unproductive sleep, leading to increased fatigue, poor body healing and lack of brain regeneration.
As I was looking at a patient’s hypnogram, I realized that it also looks like our daily work schedules. With constant interruptions, it can be difficult to get any productive work done. It’s been said that only 20% of our time at work is truly productive. With the barrage of emails, colleagues and staff dropping by, phone calls and pages, It’s a wonder that we can get anything done at all. If you plotted all the interruptions through an 8 hour workday, I bet it’ll look very similar to what you see on a hypnogram with interrupted sleep. The first figure is a relatively “normal” night’s sleep, except that it took a while to fall asleep. Notice that the person reached all the sleep stages and for the most part, had extended periods of all sleep stages. In the second figure, notice how the person keeps waking up repeatedly.
Even during a session with a patient, there are just too many interruptions. Here are the 5 most common interruptions that can disrupt your visit with your doctor:
1. Phone calls for the doctor or the patient. Needless to say, they can be really annoying, and counterproductive to developing a positive patient-doctor relationship. I make it a point not to take any phone calls, unless it’s a true life-or-death emergency.
2. Staff members popping in for various reasons, such as asking a non-urgent question, or getting supplies. I consider the time that I spend with patients precious, and any interruptions can be very disruptive.
3. The doctor is looking at the computer screen rather than looking at you. Unfortunately, it’s one of the necessary evils of modern medicine. Until Apple creates their own electronic medical record, patient visits will become more impersonal.
4. Computer/technology glitches. For me, it’s rare that an hour goes by without minor or major computer problems. It can range from hardware issue to software glitches. Calling tech support is painful while seeing patients. Once in a while, the electronic medical records goes down, and we have to use (gasp!)—paper.
5. Missing or broken medical equipment. There are dozens if not hundreds of supplies, instruments or equipment that must be stocked, maintained or serviced. Even one missing ear speculum size can be disruptive, even in the best of circumstances.
For the writers out there, you know that it takes about 15 to 30 minutes to get into the creative “groove.” Even is you can start writing again, you’ve lost about 30 minutes of your best material. Similarly, once you’ve developed a productive patient-doctor interaction, any interruption will diminish the quality and outcome of the relationship. As you can see, frequent interruptions during the work day can can be just as damaging as interrupted sleep.
When you see your doctor, what’s the one most annoying thing that interrupts your visit?
August 7, 2014 by Steven Park
Sleep position is a perennial topic that you’ll see often talked about in the media. In most cases, your sleep position is thought to predict your personality type. However, there’s a simpler explanation for why you may prefer to sleep on your side or on your tummy. This has to do with the shape of your face, and in particular, the size of your upper airway.
About once every few months, I’ll see a woman who complains of 4 weeks of frequent sinus infections, facial pain and misery. She was given multiple courses of antibiotics and allergy medications, all with only temporary relief. When I examine her upper airway, it’s usually very narrow, especially when she’s lying flat on her back. I ask her about her sleep position, and she’ll state that she likes to sleep on her back. I don’t believe her. Then I ask her what her favorite sleep position was 3 years ago. She replies that she used to sleep on her stomach. When did she change? About 4 to 5 weeks ago. Why did she change? Her dermatologist told her that she’ll get wrinkles on her face if she sleeps on her stomach.
Not unexpectedly, after switching back to her tummy during sleep, her sinus problems get better. In addition, I make sure that she stop eating close to bedtime and that her nasal breathing is optimized. What’s happening is that on her back, her tongue falls back more due to gravity, and during deep sleep, with total muscle relaxation, she stops breathing and keeps waking up. Poor sleep quality over time will cause sinus migraines, and even more facial wrinkles.
In the video below, I talk about how your facial shape can predict your sleep position.
If you’ve had to change your sleep position for whatever reason, why did you do so, and did it affect your sleep quality?