July 12, 2011
A new study out of Australia showed that in children with obstructive sleep apnea, their blood pressure levels were higher while awake just before sleep onset and during sleep. Overall, their blood pressure was 10-15 mm Hg higher compared with controls. Blood pressure was elevated, regardless of the severity of sleep apnea. The authors argue that thresholds for mild forms of sleep-disordered breathing needs to be reassessed, and that benign snoring should not be considered benign anymore.
I totally agree with the study authors. Sleep apnea doesn’t begin in middle age—it begins during the early childhood years. Having smaller jaws and more narrow airways predisposes to additional inflammation, causing lymphoid tissues (tonsils and adenoids) to become larger, which causes even more breathing problems. Taking out tonsils and adenoids are usually the first line therapy for most children with sleep apnea, but a significant number of children will have persistent sleep apnea, despite surgery. Since most children undergoing adenotonsillectomy don’t have sleep studies before and after their procedures, we’re probably missing a large number of children with persistent obstructive sleep apnea, despite subjective and clinical improvement in their symptoms.
Addressing these issues early on could potentially prevent many of the complications that may occur later in adulthood. A child that doesn’t sleep well due to breathing problems can manifest with a number of medical conditions, such as ADHD, asthma, developmental delay, bedwetting, ear infections, or even mood disorders. The public health implications are potentially huge.
May 16, 2011
It’s commonly accepted that suffering from urinary symptoms can prevent you from getting a good night’s sleep. However, a recent study confirms more recent findings that suggest that poor sleep itself can lead to lower urinary tract symptoms (LUTS), such as incontinence, and nighttime urination. This study prospectively followed over 1600 men and 2500 women and found that having poor sleep significantly predicted later development of LUTS.
For example, short sleep duration and poor sleep quality doubled the likelihood of LUTS in men and increased the risk by 66% in women. Poor sleep itself was associated with an 80-90% increased odds of developing urinary incontinence and nocturia.
This study’s results aren’t surprising, since there have been numerous studies in the past showing that most people who go to the bathroom at night do so not because they make too much urine, but because they stop breathing and then wake up to go to the bathroom. (Not breathing at night makes your kidneys make more urine). Another recent study revealed that going to the bathroom two or more times per night increases your risk of dying from any cause by over 50%! This makes sense, since most of these people will have some degree of untreated obstructive sleep apnea.
If you feel like to have to go to the bathroom too often or get up at night to go to the bathroom more than 1-2 times every night, it may be worthwhile to address your sleep problems first before seeing a urologist.
Those of you with known obstructive sleep apnea, how many of you had any of these urinary symptoms before being diagnosed with sleep apnea?
November 18, 2010
A good primary care doctor will ask good questions about your medical problems, but quality of life issues, especially involving chronic medical conditions, is not asked about. This conclusion was found in a recent article published in the Mayo Clinic Proceedings. Jane Brody of the New York Times wrote an excellent article summarizing the findings. However, I was disappointed that she didn’t mention anything about the importance of asking about sleep. I can argue that lack of quality sleep (or quantity) can aggravate, if not cause almost every medical condition that she mentions in her article (diabetes, arthritis, ADHD, IBS, cancer, urinary problems, sexual dysfunction, anxiety, depression).
In medicine, it’s commonly assumed that chronic disease can cause poor sleep. But there are numerous studies that show that poor sleep can cause or aggravate each of the medical conditions mentioned above. Furthermore, since such a high proportion of the population has undiagnosed obstructive sleep apnea (24% of men and 9% of women, and over 50% as seniors), it’s a travesty that doctors almost never ask about sleep, and even if they do ask, most end up prescribing a sleeping pill.
Does your doctor ask about how well you sleep? If so, how is it addressed?
June 8, 2010
Over the past year, ever since the birth of our third son, Brennan, I've been more tired than usual. Not too unexpected when you have a newborn, right? Add to this having to help my wife tend to the needs of our two older boys, who are 7 and 10. But even now when Brennan is sleeping well through the night, and I'm sleeping about 7 hours every night, I'm still more tired than I used to be, despite running 3 times per week, and being as fit as ever. Could I be going through male menopause?
The Facts of Male Menopause
I wrote last month about how mothers can suffer from poor sleep due to the effects of menopause on sleep quality, but what about fathers? You may have heard about male menopause, or more precisely, andropause. It's not that well known, and even if it happens, it's so slow and insidious that most men don't realize it's happening.
Well, it turns out that men go through a similar transition during the mid-life years. Not only does testosterone slowly drop, but thyroid levels as well. Our traditional medical culture and even holistic and alternative doctors sometimes argue that aging is a deficiency of certain hormones, vitamins or minerals, and that replacement using synthetic or natural supplements is the answer. But is that the only answer?
Most people think that this is a natural part of aging, along with the typical memory loss, balding, wrinkles and lowered energy and stamina. But what if I told you that I routinely see even young to middle aged men who complain about hot flashes, night sweats, mood swings, insomnia and irritability—or all the prevailing symptoms of menopause?
Aging As A Consequence of Poor Sleep
In my book, Sleep, Interrupted, I describe a sleep-breathing paradigm where all modern humans are on a continuum, where we're all susceptible to sleep-breathing problems to various degrees.
As you age, it's expected that overall, you'll keep moving up this continuum to the point where sleep breathing problems become much more serious as in obstructive sleep apnea. Not only do we sag and bulge on the outside as we get older, it also happens on the inside, including your upper airway. And as your airway becomes narrower, the more trouble you'll have breathing while sleeping, and this in turn will make you wake up more and obstruct more.
Women experience more dramatic changes in hormone levels (particularly progesterone) that affect upper airway patency, but levels of testosterone and even small amounts of progesterone can also influence upper airway muscle tone in men as well; Not to mention the typical weight gain that occurs in the middle years, leading to even more narrowing of the upper airway. Adding any degree of inflammation to the upper airway (such as from a cold, allergies, or reflux) can cause more frequent obstructions and arousals. Poor sleep efficiency leads to weight gain, and weight gain narrows the throat.
Sleep Apnea And Aging
It's a given that as you age, your upper airway begins to narrow gradually, aggravated intermittently with additional narrowing from inflammation. This is also why men begin to develop cardiovascular disease as they get older. Women are somewhat protected before menopause, but afterwards, they begin to catch up when it comes to rates of heart disease. As you slowly move up the sleep-breathing continuum, your risk of developing obstructive sleep apnea increases, and once it begins, a vicious cycle begins, where poor sleep aggravates weight gain, and weight gain aggravates poor sleep.
Poor sleep (by causing a physiologic form of stress) also causes major hormonal changes by lowering your thyroid levels, as well as your reproductive hormones. So naturally, if you test for thyroid or testosterone levels, it may come back on the low side. Not too unexpectedly, supplementing with replacement hormones helps in some cases, but not all the time.
We know that untreated obstructive sleep apnea (OSA) can aggravate or cause routine medical conditions such as diabetes, high blood pressure, depression/anxiety, heart disease, heart attack and stroke. Your risk of car accidents also increases anywhere from 3 to 10 times normal if you have OSA. Add to this all the other common expected conditions that you may experience as you get older: frequent bathroom trips, balding, erectile dysfunction, hearing loss, and even Alzheimer's.
Taken at face value these seemingly disparate symptoms of old age aren’t all that unexpected. However, if you look at them from the perspective of my sleep breathing paradigm, you’ll begin to see how it’s your breathing and not necessarily your age that’s making you feel sick and tired.
Too Many Bathroom Trip—Risky For Your Health
It's been shown that going to the bathroom frequently at night is not because you're making too much urine, but because you stop breathing and you think you have to go to the bathroom. One recent study showed that going to the bathroom two or more times per night increases your chances of dying by 50%. There have even been many anecdotal reports of hair regrowth after definitive treatment for sleep apnea. Erectile dysfunction (ED) is a very well-known complication of sleep apnea. Having ED can predict the presence of sleep apnea in the majority of patients.
Brain Damage From Poor Breathing While Asleep
Untreated sleep apnea also increases your chances of microscopic strokes and small vessel blockages in multiple, critical areas of the brain. One recent study showed that sleep apnea patients have 20% smaller brain volume in the Mammary bodies. Another showed smaller brain tissue densities in critical areas of the brain that controls memory, executive function, breathing and respiration. Untreated sleep apnea patients have much more viscous (thick) blood that can stagnate and clot in small vessels in the brain. One area that's particularly sensitive are the small vessels that supply the high-frequency sensing areas of the inner ear.
All these issues begin when you're young, but begin to manifest in your middle years, progressing to full-blown medical complications when you reach your 60’s and 70’s. As you can see, how narrow you upper breathing passageways are determines how quickly you age or how often you become sick. Now that I'm in my mid-40s, if I don't get at least 7 hours of sleep, or if I eat later than usual, I definitely feel worse the next day. This is why it's important to do everything possible to breathe well at night while sleeping, in addition to a healthy lifestyle that includes a good diet, regular exercise and smart decisions when it comes to your sleep.
April 21, 2010
Spring is in the air, and so are the tree pollens. Millions of people suffer this time of the year from sneezing, scratchy, itchy eyes, nose and throats, nasal congestion and chronic cough. It's also a given that if you have allergies, you won't sleep as well, along with everything from asthma, cough, and sinusitis to diarrhea. So how do allergies cause sleep problems, and in general, and how does it specifically cause or aggravate obstructive sleep apnea?
When Allergies Lead to Something Worse
There are already tomes of articles, books and websites offering tips for allergy sufferers including traditional options like nasal saline irrigation, homeopathic remedies, and using a HEPA filter to prescription medications and allergy shots. But again, how can having a runny nose cause you not to sleep well at night? I've combed through numerous medical and internet resources and to date, I haven't found one good explanation.
However, looking at it from a sleep-breathing standpoint, it makes total sense: any degree of nasal congestion, whether from allergies, colds, or even weather changes, causes a slight vacuum effect downstream in the throat which can aggravate tongue collapse, especially in certain susceptible people. Who then, are susceptible to tongue collapse? Almost every modern human!
It's All In Your Jaws
To be more specific, the smaller your jaws, the more likely you'll sleep poorly when you have allergies. Even if you're completely normal, having a stuffy nose can suddenly cause your tongue to fall back and block your breathing. Plugging your nose has been shown to cause obstructions and arousals during sleep. This is why you'll toss and turn when you have an allergy or a simple cold.
Many people with allergies and small mouths will also have grooves or indentations along the side of their tongues. This is called tongue scalloping. Since the tongue and other soft tissues grow to their genetically predetermined size, and due to crowding from having smaller jaws, the teeth leave their imprints along the side of the tongue. If you have additional inflammation from gastric reflux that's a given with sleep-breathing problems, then this scalloping problem gets worse. Not too surprisingly, tongue scalloping is predictive of having apneas, hypopneas, or oxygen drops in almost 90% of people.
Allergies From Stress?
So then, why do allergies happen in the first place? Again, there are tons of proposed explanations that I don't have the space for, but here's a simple concept from Robert Sapolsky's classic book, Why Zebras Don't Get Ulcers:
Humans can handle big stresses such as a major catastrophe, a death in the family, or running away from a tiger. In these scenarios, your stress response leads to an intense activation of your immune system (in addition to your nervous system's fight or flight response). Once the stress is over, your immune system's activity level drops down to normal, but only after it dips below normal for a short period of time. During this short period, you're also more susceptible to getting sick.
However, modern societies don't have very big stresses such as running from a saber tooth tiger. Rather, we have multiple micro-stresses spread throughout the day such as being honked from the rear on the way to work, your boss yelling at you, or your computer crashing. These little stresses push your immune system's activity higher and higher, with not enough time for it to recover and go back to normal levels. After a certain point, your immune system is on constant overdrive, leading to the typical allergic or autoimmune conditions that are all-too-common today.
When Your Allergy is Not An Allergy
This process also explains why you may also have a chronically runny nose. This is called chronic or nonallergic rhinitis, when the involuntary nervous system in your nose overreacts to irritants, chemical, odors, or weather changes (either pressure, temperature, or humidity changes). Symptoms include runny nose, sneezing, nasal congestion, post-nasal drip and headaches, and is often mistaken for regular allergies. This condition may respond to regular allergy medications, but not as well. Either way, inflammation and swelling can also cause nasal congestion, leading to poor quality sleep.
Overcoming Your Allergies
If you have classic allergies, you must start with the basics: Avoid outdoor activity on high-pollen days, shower before bedtime to get the allergies out of your hair, don't wear shoes indoors, get a HEPA filter, and take over-the-counter medications as needed. Some people benefit from routine use of HEPA filters as well in their bedrooms. You may have to see your doctor if conservative measures don't help.
There are various over-the-counter allergy medications. The newer, nonsedating antihistamines block the effects of histamine, which is what causes watery, itchy, runny eyes and nose. The most common brands are Claritin, Allegra, and Zyrtec. They all work differently in different people, so the only thing you can do is to try each one and see which you prefer. Although they are nonsedating in theory, there are reported cases of drowsiness with all three. Benadryl is an older antihistamine that's very effective for allergies, except that many more people may get drowsy.
If your nose is stuffy, then two options are nasal decongestant sprays (which you can only use for 2-3 days) or decongestant pills. Routine nasal saline irrigation can also help your breathing and sleep.
There are a number of prescription medications, including topical nasal steroid or topical steroid sprays. Leukotriene phosphate inhibitors, such as Singulair, and various others also available. Oral steroids can also be useful in emergency situations. As a last resort, an allergy evaluation with shots are a consideration.
Regardless of which way you treat your allergies, it's important to follow all my recommendations for better breathing while sleeping, such as avoiding eating or drinking alcohol within 3-4 hours of bedtime, sleeping on your side or stomach. Having a stuffy nose for whatever reason can trigger breathing pauses downstream, ultimately giving you a bad night's sleep.
March 1, 2010
Even if you don't have any sleep problems or medical issues, the quality and quantity of sleep can play an important role in how well you function during the day. This study showed that in normal, healthy children, shorter sleep duration was associated with lower IQ scores and perceptual reasoning.
In this age of information and programming overload, children in general have very poor sleep habits. In many cases, parents' poor sleep habits set a bad example. The implications of this study also apply to grownups as well.
How long do your children sleep? Do they have a regular routine before going to bed, or is it a struggle every night?
July 31, 2009
November 14, 2008
Once in a while, I see male patients that reveal that they sometimes cry in the mornings upon awakening from sleep. There are two major reasons: The first group includes men who can’t stay asleep or keep waking up, feeling exhausted when the alarm goes off, and they feel as if they only slept for 2-3 hours. The other group includes men who undergo definitive treatment for obstructive sleep apnea (whether via a positive air pressure machine, a dental device or via surgery), who are able to achieve deep sleep for the first time in years. These men have tears of joy.
The most memorable experience is one man who had severe sleep apnea who couldn’t tolerate a positive pressure mask, and after a long discussion, decided to undergo major throat surgery involving the soft palate and tongue. He noted that one morning, a few weeks after the surgery, he awoke and for the first time in years, felt light he achieved deep sleep and felt clear headed. This is when he noticed his eyes welling up with tears.
Unfortunately, I see more people in the former group, in women as well as in men. One woman even told me that she curses the mornings when she has to wake up.
Do you ever cry because you can’t sleep?