Sleep Apnea: It's Consequences and Symptoms

Medical Conditions Related to Sleep Apnea

Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.

Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. Research suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Apnea itself may also cause pressure changes that trigger GERD. Obesity is common in both conditions, and more research is needed to clarify the association.

Polycystic Ovary Syndrome (PCOS). Obstructive sleep apnea and excessive daytime sleepiness appear to be associated with polycystic ovary syndrome (PCOS), a female endocrine disorder. About half of patients with PCOS also have diabetes. Obesity and diabetes are associated with both sleep apnea and PCOS and may be the common factors.

Complications

Sleep apnea can lead to a number of complications, ranging from daytime sleepiness to possible increased risk of death. Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.

Daytime Sleepiness

Daytime sleepiness is the most noticeable, and one of the most serious, complications of sleep apnea. It interferes with mental alertness and quality of life. Daytime sleepiness can also increase the risk for accident-related injuries. Several studies have suggested that people with sleep apnea have two to three times as many car accidents, and five to seven times the risk for multiple accidents. Undertreated sleep apnea is a major risk factor for injury at factory and construction work sites.

Effects of Sleep Apnea on Heart and Circulation

Sleep-disordered breathing is very common among patients with heart problems such as high blood pressure, heart failure, stroke, heart attack, and atrial fibrillation. This link may be because both cardiovascular conditions and sleep apnea share a common risk factor of obesity. However, increasing evidence suggests that severe OSA is an independent risk factor that may cause or worsen a number of heart-related conditions.

High Blood Pressure. Moderate-to-severe sleep apnea definitely increases the risk for high blood pressure (hypertension) even when obesity is not a factor. Doctors are not certain whether treating OSA with CPAP reduces the risk for high blood pressure, but studies indicate that CPAP may help prevent or decrease high blood pressure.

Coronary Artery Disease and Heart Attack. Sleep apnea appears to be associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. Studies suggest that patients with moderate-to-severe obstructive sleep apnea have a higher risk for heart attack.

Stroke. Sleep apnea may increase the risk of death in patients who have previously had a stroke.

Heart Failure. Up to a third of patients with heart failure also have sleep apnea. Central sleep apnea often results from heart failure. Obstructive sleep apnea can cause heart damage that worsens heart failure and increases the risk for death.

Atrial Fibrillation. Sleep apnea may be a cause of atrial fibrillation (irregular heartbeat).

Other Adverse Effects on Health

Sleep apnea is associated with a higher incidence of many medical conditions, besides heart and circulation. The links between apneas and these conditions are unclear.

• Diabetes. Severe obstructive sleep apnea is associated with type 2 diabetes.
• Obesity. When it comes to sleep apnea and obesity, it is not always clear which condition is responsible for the other. For example, obesity is often a risk factor and possibly a cause of sleep apnea, but it is also likely that sleep apnea increases the risk for weight gain.
• Pulmonary hypertension (high pressure in the arteries of the lungs).
• Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
• Seizures, epilepsy, and other nerve disorders. There may be an association between seizures and obstructive sleep apnea, especially in older adults. Some studies have shown treatment of obstructive sleep apnea may help in the control of refractory seizures.
• Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder may cure the headache.
• High-risk pregnancies. Sleep apnea may increase the risk of pregnancy complications, including gestational diabetes and high blood pressure.
• Eye disorders, including glaucoma, floppy eyelid syndrome, optic neuropathy conjunctivitis, dry eye, and various other infections and irritations. Some of these latter symptoms may be associated with CPAP treatments for sleep apnea.

Psychological Effects

Studies report an association between severe apnea and psychological problems. The risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder.

Effects on Bed Partners

Because sleep apnea so often includes noisy snoring, the condition can adversely affect the sleep quality of the bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.

Effects in Infants and Children

Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system.

Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.

Symptoms

People with sleep apnea usually do not remember waking during the night.

Symptoms in Adults

Symptoms may include:

• Excessive daytime sleepiness. Generally, patients risk falling asleep during the day while performing routine activities such as reading, watching TV, sitting inactively, lying down, or riding in a car while a passenger or stopped for a few minutes in traffic. Usually, these brief episodes of sleep do not relieve their overall sense of sleepiness.
• Morning headaches.
• Irritability and impaired mental or emotional functioning. These types of symptoms are directly related to interrupted sleep.
• Snoring. Bed partners may report very loud and interrupted snoring. Patients experience snoring associated with choking or gasps. This often occurs in a crescendo pattern with the loudest noises occurring at the very end. Snoring is more likely to occur when lying on the back. Patients often suffer from frequent arousals during sleep because of snoring.

Symptoms in Children

Sleep apnea occurs in about 2% of children. They may have symptoms that differ from adults, including:

• Longer total sleep time than normal in some children, especially obese children or those with severe apnea.
• More effort in breathing (flaring nostrils, heaving chests, sweating). The chest may have an inward motion during sleep.
• Behavioral difficulties without any obvious cause, such as hyperactivity and inattention.
• Irritability
• Bed-wetting
• Morning headaches
• Failure to grow and gain weight

Diagnosis

The symptoms of obstructive sleep apnea are not very specific. This means that most people who snore at night or who feel tired during the day probably do not have sleep apnea. Other medical reasons for daytime sleepiness should be considered by your doctor before referral to a sleep center for diagnostic sleep tests. They include:

• Having to work excessive hours or varying shifts (nights, weekends)
• Medications (tranquilizers, sleeping pills, antihistamines beta blockers, many others)
• Alcohol abuse
• Medical conditions (such as underactive thyroid, abnormal blood sodium levels, high blood calcium levels)
• Self-imposed short sleep time
• Other sleep disorders, such as narcolepsy, insomnia, or restless legs syndrome
• Chronic fatigue syndrome
• Depression or dysthymia

Symptoms or findings that make the need for evaluation by a sleep specialist include:

• Sleepiness is affecting patient's quality of life
• Sleepiness on-the-job places the patient or others in danger
• Others have observed apnea or breath-holding episodes while asleep
• Other medical illnesses that may be worsened by obstructive sleep apnea are present.
• Children who are snoring a lot and are irritable, not thriving or growing well, or having behavioral issues

If symptoms suggest obstructive sleep apnea or other sleep disorders, further diagnostic testing will be performed. A sleep specialist or sleep disorders center will perform an in-depth medical and sleep history and physical exam. Centers should be accredited by the American Academy of Sleep Medicine.