Sleep Apnea
Definition
Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. Sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. There are two types of apnea: central and obstructive. Central apnea occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations. Obstructive sleep apnea is far more common and occurs when air cannot flow into or out of the person’s nose or mouth although efforts to breathe continue. The frequent interruptions of deep, restorative sleep often lead to daytime sleepiness and may be associated with an early morning headache. Early recognition and treatment of sleep apnea is important because it may be associated with irregular heartbeat, high blood pressure, heart attack and stroke.
Sleep apnea occurs in all age groups and both sexes but is more common in men. It is estimated that as many as 18 million Americans have sleep apnea. People most likely to have or develop sleep apnea include those who snore loudly and are overweight, or have high blood pressure, or have some physical abnormality in the nose, throat, or other parts of the upper airway.
Sleep Apnea can be caused when the throat muscles and tongue relax during sleep and partially block the opening of the airway. When the muscles of the soft palate at the base of the tongue and the uvula relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether.
During the apneic event, the person is unable to breathe in oxygen resulting is low levels of oxygen and increased levels of carbon dioxide in the blood. This results in a signal being sent from the brain to the upper airway muscles to open the airway; breathing is resumed, often with a loud snort or gasp. Frequent arousals, needed for breathing to restart, prevent the patient from getting enough restorative sleep.
Symptoms
People with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffer. Sleep apnea symptoms include symptoms suggesting depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. It is estimated that 50 percent of sleep apnea patients have high blood pressure. Risk for heart attack and stroke may also increase in those with sleep apnea.
Treatments
Physical or Mechanical Therapy
Nasal continuous positive airway pressure(CPAP) is the most common effective treatment for sleep apnea. In this procedure, the patient wears a mask over the nose or the nose and mouth during sleep, and pressure from an air blower forces air through the nasal passages. The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. Nasal CPAP prevents airway closure while in use, apnea episodes return when CPAP is stopped or used improperly. Variations of CPAP include varying pressures with inspiration and expiration and starting with a low pressure that increases slowly to allow patient to fall asleep before the full prescribed pressure is applied. Various mask types are available for optimal patient comfort.
Dental appliances that reposition the lower jaw and the tongue have been helpful to patients with mild to moderate sleep apnea or those who snore but do not have apnea. A dentist or orthodontist is usually the one to fit the patient for the device.
Surgery
Some surgical procedures are used to increase the size of the airway, none of them are completely successful or without risks. More than one procedure may need to be tried before the patient realizes any benefits.
Some of the more common procedures include removal of adenoids and tonsils, nasal polyps or other growths, or other tissue in the airway and correction of structural deformities.
- Uvulopalatopharyngoplasty (UPPP) is a procedure to remove excess tissue at the back of the throat.
- Laser-assisted uvulopalatoplasty (LAUP) is done to eliminate snoring.
- Tracheostomy is used with severe, life-threatening sleep apnea. A small hole is made in the windpipe and a tube is inserted into the opening. The tube stays closed during waking hours and the person breaths and speaks normally. It is opened for sleep, bypassing any upper airway obstruction. This is an extreme measure that is rarely used. Other procedures: If sleep apnea is due to deformities of the lower jaw, benefits may be seen from surgical reconstruction.
Other Therapies
Overweight persons can benefit from losing weight. Alcohol and sleeping pills can be avoided. In patients with apnea only in one body position (such as only when sleeping on their backs), the patient can learn to sleep in alternate positions.
Restless Legs/Periodic Leg Movements
Restless Legs Symptoms
- An urge to move the legs, often accompanied by uncomfortable sensations in the legs, usually described as a creeping or crawling feeling but sometimes as a tingling, cramping, burning or pain. The arms may be affected, but this is much less common.
- The need to move the legs to relieve the discomfort, by stretching or bending, rubbing the legs, tossing or turning in bed, or getting up to pace the floor. Moving usually offers temporary relief of the symptoms.
- A definite worsening of the discomfort when lying down or sitting.
- A tendency to experience the most discomfort late in the day and at night.
- Sleep disturbances are common with RLS. If leg twitching or jerking is present during sleep, a related disorder – periodic limb movements during sleep (PLMS) – may be the cause.
Treatment
- Dopaminergic agents such as carbidopa-levodopa.
- Dopamine agonists such as ropinirole, pergolide, and pramipexole.
- Benzodiazepines such as clonazapam and temazepam.
- Anticonvulsants such as carbamazepine and gabapentin
- Iron if patients serum ferritin levels of < 50 mcg.
Narcolepsy
Narcolepsy is a chronic neurological (affecting the brain or nerves) disorder than involves the body’s central nervous system. The central nervous system is the “highway” of nerves that carries messages from your brain to other parts of your body. For people with narcolepsy, the messages about when to sleep and when to be awake sometimes hit roadblocks or detours and arrive in the wrong place at the wrong time. Someone with untreated narcolepsy may fall asleep at times when they want to be awake. People with narcolepsy lack a chemical in the brain called hypocretin which normally stimulates arousal and helps regulate sleep. About one in 2,000 people suffer from narcolepsy. It affects both men and women and the onset of symptoms in usually seen after puberty begins.
Symptoms
- Cataplexy – sudden loss of muscle control ranging from slight weakness (head droop, facial sagging, jaw drop, slurred speech, buckling of knees) to total collapse. It is commonly triggered by intense emotion (laughter, anger, surprise, fear) or strenuous athletic activity. Most persons with narcolepsy have some degree of cataplexy.
- Sleep paralysis – being unable to talk or move for a brief period when falling asleep or waking up. Many persons with narcolepsy suffer short-lasting partial or complete sleep paralysis.
- Hypnagogic hallucinations – vivid and often scary dreams and sounds reported when falling asleep. People with narcolepsy may experience hypnagogic hallucinations and sleep paralysis as well.
- Automatic behavior – familiar, routine or boring tasks performed without full awareness or later memory of them.
Treatment
Treatment with medications is the first line of defense. Changes in behavior combined with drug treatment have helped most people with narcolepsy improve their alertness and enjoy an active lifestyle.
Parasomnias
Nightmares are dreams with vivid and disturbing content. They usually involve an immediate awakening and good recall of the dream contest.
Sleep Terrors include arousal, agitation, large pupils, sweating and increased blood pressure. Sleep Terrors most often occur during childhood. The child appears terrified, screams and is usually inconsolable for several minutes, after which he or she relaxes and returns to sleep. Sleep terrors usually take place early in the night and may be combined with sleepwalking. The child typically does not remember or has only a vague memory of the terrifying events.
REM behavior disorder involves complex, vigorous or violent behaviors, sometimes associated with dream-like thought and images. Patients complain of sleep disruption, violent behavior with injuries to themselves or to their bed partner. Patients are usually middle-aged or elderly and about one third have an associated neurological disease.