Interrupted sleep wearing and dangerous
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Font: * * * * Peggy Curran, CanWest News Service
Published: Saturday, October 14, 2006
MONTREAL --There's a little sucking noise as an opening at the back of the throat collapses. The man stops breathing, gasps for air, wakes up and drifts quickly back to sleep. All through the night, every night, this sequence repeats itself -- perhaps, 40, 70, even 110 times an hour.
He hasn't got a clue. Come morning he will wonder why another long night's journey into day has left him feeling so weary, lousy, confused and blue.
"Usually, the patient doesn't even know it's happening," said Jacques Montplaisir, director of the Universite de Montreal's sleep clinic at Hopital Sacre Coeur. "The brain is awake, but behaviourally the person is drowsy, groggy. The patient feels he sleeps well."
It's the sleepiness that finally sends the patient to seek help, he said. "Now that people are more aware, sometimes the bed partner brings the person in for consultation. They say, 'That's crazy, you stop breathing and it makes me nervous."'
"These guys are choking and dying all night," says John Kimoff, director of the sleep laboratory at the McGill University Health Centre, which is "swamped" with demands for diagnosis and treatment of sleep apnea and other medical sleep disorders.
Sleep apnea was once regarded as an ailment for heavy-snoring, pot-bellied men, and there's still some truth to the stereotype. Official statistics say four per cent of men and two per cent of women suffer from apnea. However, experts suspect the incidence is at least double that, and apt to keep climbing as the general population grows older and pudgier.
"With half of North Americans now overweight or heading in that direction, there is a serious risk factor for sleep apnea," said Gilles Lavigne, president of the Canadian Sleep Society.
"One can certainly surmise that with increasing obesity epidemic in western populations (sleep apnea's) prevalence is on the rise," said Kimoff, who cautions against making sweeping generalizations. "A substantial portion of our apnea patients are not obese, and not all obese people have apnea."
Still, ask a bariatric surgeon who does gastric bypass -- often the last resort for patients who have failed to lose weight by any other means -- and Kimoff said you'll find roughly 70 per cent of male and 50 per cent of female patients have apnea.
Meanwhile, pediatricians are referring more cases of sleep apnea in children who are overweight.
"It's been known since the early '80s that there is a link between poor sleep patterns and poor school performance, lack of concentration and poorly focused attention," said Marc Baltzan, a sleep specialist at Montreal's Mount Sinai Hospital. "Now we are seeing cases of children who are snoring, obese, have high blood pressure -- even cases of child heart failure because of sleep apnea."
"There are all kinds of metabolic risks associated with obesity, so sometimes it is hard to separate the apnea and the obesity," said Montplaisir. "Because people are becoming more and more overweight, the question of apnea is going to become more important and will be looked at more closely."
Indeed, the latest research suggests that obesity and poor sleep are as tightly linked as a Quarter Pounder and its bun. It appears people who sleep well have more success keeping off those extra pounds, which helps stave off the buildup of flabby tissue around the neck, which collapses during the night as the apnea patient struggles to breathe.
Yet, more and more, the condition is also being detected in people of all ages and widths. Family history, tonsils, the shape of the jaw or the size of the tongue, depression and excessive daytime weariness are key factors in determining whether a person may suffer from apnea.
Pregnant women and young mothers, men in excellent physical condition and small children are being booked in for sleep studies and fitted with the masks and mouth guards needed to keep airways open and regulate breathing through the night.
New evidence suggests that some women may develop apnea during pregnancy, which may persist well after they lose the added belly weight. A newly published study by MUHC sleep specialist Kateri Champagne cites apnea as a risk factor contributing to hypertension in pregnant women.
"The image of the sleep apnea patient is Monsieur Michelin (the tire man)," said Lavigne, a sleep researcher at U de M. "But it's not just big people. Very thin people can also have sleep apnea."
Cinzia Cuneo is tall and thin with a long oval face. She has woken with headaches since she was a child. As an adult, she snored heavily. Last year, she heard about sleep apnea and thought she recognized herself. A sleep study confirmed her diagnosis.
Julie Dallaire is a nurse at the Montreal Chest Institute, where she runs a support group for patients with sleep apnea. She helps those who have recently been diagnosed better understand their illness and its consequences, and adjust to the idea of wearing a mask to bed. Only rarely does she feel compelled to tell them that she, too, suffers from sleep apnea.
Slim and vivacious, a former competitive swimmer with two small children, Dallaire doesn't know how long her sleep was disrupted.
"Everybody's tired. And at some point, we get used to being tired. It becomes natural, and we think that everybody feels the same." But as Dallaire listened to the weary young mothers who came in to the clinic and left with a diagnosis of apnea, she thought she recognized herself and asked for a sleep study.
She doesn't know whether she had apnea before her pregnancies. "Maybe, because I didn't have children, I was able to manage. Even if the quality of my sleep was not good, I was able to catch up, or at least function. And now that I have two children, I am not able to catch up because the sleep is interrupted. Finally, it became too hard and too complicated."
If left untreated, sleep apnea can have huge implications on health, increasing the risk of high blood pressure, Type 2 diabetes, heart attack or congestive heart failure and stroke. Meanwhile, lost sleep will impede memory and cloud judgement and concentration.
Kimoff said there is growing evidence that treatment -- in most cases, a device known as a continuous positive airway pressure mask -- can reduce cardiovascular risk.
However, that depends on recognition and referral. For many patients, Kimoff said, it can be a long, frustrating journey to get anyone to pay attention, never mind sign them up for a sleep study. "They've been talking to their doctor for years. 'Oh doc, I'm always tired.' And the answer is: 'It's because you are fat and lazy -- lose weight."'
Montplaisir said it's not always easy to get people who have been diagnosed to accept the idea of wearing a mask to bed, because they find it daunting or claustrophobic. "It's not a very friendly treatment. So we a have problem with compliance," Montplaisir said. "Sometimes, at 4 o'clock in the morning they will just throw it away and say 'I'm going to sleep three hours now without anything."'
Lavigne, who trained as a dentist before shifting his energies into sleep, has developed a brace that pushes the jaw open and out for apnea patients who can't or won't wear the mask. "They say, 'my wife laughs when I sleep with it; I don't like to travel through customs with it; I can't use it when I'm fishing; I can't use it on my boat; I have a new girlfriend."' Yet Lavigne said apnea patients who do get used to the treatment are often amazed at how much better they feel. "Their blood pressure is down, they are less sleepy, have fewer memory problems, even say they have better sex."
"It's quite intimidating at the beginning. I thought I would not ever be able to sleep with this," said Cuneo, 45. "I feel like an elephant." But after the first night, with air pumping into her airways instead of being sucked out, she awoke refreshed for the first time in her life and ready to fork out $2,000 for a device of her own.
"It's fantastic -- the beauty of finding a solution that is mechanical, not chemical," said Cuneo, who is an engineer. "This is so much better than taking sleeping pills."
"It's not very romantic," said Dallaire, who worried what her husband would think when she realized she would need to sleep wearing a mask. So she was touched the morning when he joked about buying more masks -- he was so thrilled with the change in her mood and energy level.
"We normalize this feeling of tiredness," Dallaire said. "But when you reach a point where you have symptoms of depression, where you are not able to watch television at night or watch the news because you fall asleep, or you're not able to go out with friends during the weekend because you aren't in the mood or you don't have the drive to do it, it becomes a problem.
"It affects the ability to have an optimal life, to be able to do things with your spouse, to play with the children and enjoy normal things.
"That's the main difference between the sleep apnea patient and the person without sleep apnea. When you're tired and you go to bed, you are going to recuperate. Your sleep isn't interrupted, so you can have a good sleep. But someone with sleep apnea, their sleep is interrupted every time they stop breathing."
IF IT'S NOT APNEA, WHAT IS IT?
- Upper airway resistance syndrome: Sleep is interrupted when a patient is unable to get enough air and wakes gasping. Symptoms include temporal headaches in the morning. It can stem from facial irregularities like a narrow palette, an unusually large tongue or tonsils that impede airflow during the night.
- Narcolepsy: People with narcolepsy have trouble waking in the morning and fall asleep throughout the day, often at inappropriate times -- in the middle of a sentence, while laughing or feeling strong emotions, while eating or driving a car. They are also prone to hallucinate, experiencing extremely vivid dreams, often with the sensation of falling asleep or waking up.
- Restless leg syndrome: Sleep is disrupted when a patient feels a creepy or crawling sensation, especially when they rest or lie down. The patient might wake up with leg cramps or jerk periodically during the night, waking up the brain. This condition is far more prevalent in Quebec and eastern Canada than it is elsewhere on the continent, leading experts to suspect a genetic link to a common ancestor.
- Bruxism: Also known as teeth-grinding, this condition, which occurs during deep sleep, is most common among children.
- Pain: Two out of three people who have chronic pain also complain of poor-quality sleep
Obesity and sleep