Sleep Disorders : Sleep Apnea

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Sleep is important to all people however for people who live with multiple sclerosis quality sleep is critical.  Poor sleep can result in significantly increased fatigue, depression both of which have been shown to also impact cognition and memory in both healthy people and MS patients.  It is important to understand that deep sleep is the therapeutic target.  People who awaken often during sleep jump back into “alpha phase” sleep which is not a significant restorative sleep.  A person may get 8 hours sleep but if they awaken every hour on the hour they are not achieving much restorative sleep and thus still feel tired when they awaken for the day or quickly feel tired early in their day.  They may experience memory problems, cognitively perform more poorly and frequently have mood issues.

Overview:

All too often quality of rest and deep sleep are ignored by people and their body becomes accustomed to the poor sleep.  They do not realize the impact or difference of poor sleep .vs. quality sleep. Most of us have had quality sleep at one time or another.  Sleep that when you awaken truly feel refreshed.  This should be our target each and every day 7 days a week.  We often assume that such a refreshing sleep is an exception when it should be what occurs most often instead of occassionally.

Quality of sleep for people who live with multiple sclerosis can be a real game changer in quality of life.

Sleep apnea is a common disorder in which a person has one or more pauses in breathing or shallow breaths while sleeping. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound. Sleep apnea usually is a chronic ongoing condition that disrupts sleep. When breathing pauses or becomes shallow, a person often will move out of deep sleep and into light sleep. As a result, the quality of sleep is poor and the effects of poor sleep manifest during the day.

About Sleep Apnea:

Sleep apnea often goes undiagnosed. Doctors usually can’t detect the condition during routine office visits. Also, no blood test can help diagnose the condition. Most people who have sleep apnea don’t know they have it because it only occurs during sleep. A family member or bed partner might be the first to notice signs of sleep apnea.

Sleep apnea can be a serious condition.  Untreated it can increase risk of high blood pressure, heart attack, stroke, obesity and diabetes as well as result in heart failure, arrhythmias or irregular heart beats.

In multiple sclerosis, sleep apnea can result from spasms associated with MS. Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes, mouthpieces, surgery, and breathing devices can successfully treat sleep apnea in many people.

There are three common types of sleep apnea:

  • Obstructive sleep apnea, the more common form that occurs when throat muscles relax.  In this condition, the airway collapses or becomes blocked during sleep. This causes shallow breathing or breathing pauses.
  • Central sleep apnea, which occurs when your brain doesn’t send proper signals to the muscles that control breathing.  As a result, you’ll make no effort to breathe for brief periods. Central sleep apnea can affect anyone. However, it’s more common in people who have certain medical conditions or use certain medicines. Central sleep apnea can occur with obstructive sleep apnea or alone. Snoring typically doesn’t happen with central sleep apnea.
  • Complex sleep apnea syndrome, also known as treatment-emergent central sleep apnea, occurs when someone has both obstructive sleep apnea and central sleep apnea.

A study in 2014 in the Journal of Clinical Sleep Medicine a publication of the American Academy of Sleep Medicine studied 195 participants who completed a detailed sleep questionnaire and over 1/5th of them had been diagnosed with sleep apnea and one-half of the rest of the participants were at risk for the condition.

The study also showed that sleep apnea was associated with increased levels of fatigue. These findings show sleep apnea may be a common not recognized and significant contributor to fatigue and doctors should consider testing for sleep apnea in MS patients.

“Obstructive sleep apnea is a chronic illness that can have a destructive impact on your health and quality of life,” and MS patients at high risk for sleep apnea should undergo a comprehensive sleep evaluation, academy president Dr. M. Safwan Badr said in the news release.

Sleep Apnia DiagramA study in 2015 of sleep apnea published in the Journal of Neuroimaging had researchers at UCLA (University of California Los Angeles) showed that obstructive sleep apnea appears to weaken the blood brain barrier (BBB) which is of significant consequence to multiple sclerosis patients.   The blood-brain barrier acts as a mechanism by which the brain can obtain nutrients from the bloodstream, send waste from cells in the brain into the bloodstream and block unwanted materials in the blood stream from entering into the brain.  The blood brain barrier is also where immune cells cross from the blood stream into the central nervous system resulting in multiple sclerosis exacerbations (attacks).

“We found that the blood–brain barrier becomes more permeable in obstructive sleep apnea, a breakdown that could contribute to brain injury, as well as potentially enhancing or accelerating the damage,” said Rajesh Kumar, the study’s principal investigator and an associate professor in the departments of anesthesiology and radiological sciences at the UCLA Geffen School of Medicine.

“This type of brain injury in obstructive sleep apnea has significant consequences to memory, mood and cardiovascular risk, but physicians and researchers have developed pharmacologic and non-pharmacologic therapeutic strategies to repair blood–brain barrier function in other conditions,” he said.

Symptoms of Sleep Apnea:

Sleep Apnea Dangers
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The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to diagnose.

The most common signs and symptoms of obstructive and central sleep apneas include:

  • Loud snoring, which is usually more prominent in obstructive sleep apnea
  • Episodes of breathing cessation during sleep witnessed by another person
  • Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Difficulty staying asleep (insomnia)
  • Excessive daytime sleepiness (hypersomnia)
  • Attention, awareness or cognition problems
  • Irritability

Diagnosing Sleep Apnea:

If you or your partner thinks you may have sleep apnea you should contact your primary physician as soon as possible.  The physician may wish to see you or refer you directly to a sleep specialist.  When you call for your appointment ask if here is anything you should do in advance such as any dietary changes or if you should start a sleep diary.  A sleep diary is simply writing down any of the symptoms you appear to be experiencing such as those noted above along with time and date.  Make a list of medications you take, vitamins and supplements.

If you sleep with a partner it is important that they come along with you so as they can relay any information they may have in witnessing your sleep patterns such as thrashing or symptoms noted above.  Since your time with the physician is likely to be limited write down any questions you have in advance of your appointment.

Your doctor is likely to ask you a number of questions that you may with consider in advance.

For example:

  • When did you begin experiencing symptoms?
  • Have your symptoms been continuous, or do they come and go?
  • How severe are your symptoms?
  • How does your partner describe your symptoms?
  • Do you know if you stop breathing during sleep? If so, how many times a night?
  • Is there anything that has helped your symptoms?
  • Does anything make your symptoms worse, such as sleep position or alcohol consumption?

If you do not have a partner to come with you but suspect you may have sleep apnea you can use a video camcorder and record your sleep.  This can also be a good mechanism by which you can determine what may be happening with your sleep.  The same can be done if you do have a partner.  As they see sleeping issues occur they may be able to catch it on video and record it.

Evaluating Sleep Apnea:

sleep apnea infographic
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Based on what your physician sees as signs and symptoms you may be referred to a sleep specialist.  Generally speaking with multiple sclerosis it is a good idea to request of your physician that you do see a sleep specialist.  Multiple sclerosis can make sleep disorder evaluations complex and a sleep specialist will be better able to view what is happening in your sleep state.

Sleep disorder evaluations occur at a sleep clinic that often requires an overnight stay where monitoring of breathing and sleep patterns takes place.  While this may sound inconvenient perhaps even intrusive aka: “I don’t want people hearing me snore” understand the staff are trained professionals.  Their assistance in understanding what is causing your sleep disorders and intervention can make an enormous difference in your quality of sleep and as such your quality of life.

With multiple sclerosis proper and good quality of sleep are imperative towards quality of life.

Home sleep testing may also be an option but you are better off being evaluated at a sleep clinic.

Tests to detect sleep apnea may include:

  • Nocturnal polysomnography. During this test, you’re hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.
  • Home sleep tests. In some cases, your doctor may provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually involve measuring your heart rate, blood oxygen level, airflow and breathing patterns. If you have sleep apnea, the test results will show drops in your oxygen level during apneas and subsequent rises with awakenings.

Depending on results your doctor may be able to prescribe a therapy with no further testing. Portable monitoring devices do not detect all cases of sleep apnea and your physician may still desire you undergo further tests.  With obstructive sleep apnea you may be referred to an ear, nose and throat specialist to rule out issues of blockages.  If results show that you may be experiencing central sleep apnea a cardiologist may need perform an evaluation for symptoms such as irregular heart rates and a neurologist may also be warranted to investigate possible neurological causes.

Treatment of Sleep Apnea:

Sleep Apnea CartoonIt is important to understand that sleep apnea is a chronic condition and ignoring it especially if you have multiple sclerosis is very very unwise and potentially quite dangerous.

For temporary relief of symptoms while awaiting appointments and/or diagnosis and treatment you can try sleeping on your side as most forms of sleep apnea are milder when you sleep on your side. Avoid all alcohol for at least six hours before going to bed as it is known to worsen both obstructive and complex sleep apnea.  Avoid medications that are sedatives as these drugs intended to make you sleepy also can make sleep apnea worsen.

Treatment of sleep apnea depends on the severity of the condition.  In mild cases lifestyle adjustments might resolve the condition such as loosing some weight, not smoking, identifying prospect allergies and treating them or devices that open up airways.  For more severe intervention sleeping aids such as breathing assistive technologies may be called for.  Where all these mechanisms fail surgery can often correct the condition.

Things You Can Try At Home:

  • Try loosing weight.  Even minimal losses in weight can result in relieving constriction in the throat in obstructive sleep apnea. The condition will likely come back if you regain the weight.
  • regular exercise can help remove obstructive sleep apnea such as a brisk walk for at least 30 minutes per day most everyday of the week.
  • Completely avoid alcohol.
  • Avoid medications such as tranquilizers and sleeping pills as these relax the muscles in the back of your throat.
  • Alter your sleep position sleeping on your side or abdomen rather than on your back. Sleeping on your back can result in the tongue and soft palate to rest against the back of your throat and thus block your airway. Some people have sewn a tennis ball into the back of their pajamas causing them to avoid moving towards sleeping on their back.
  • Using saline based nasal sprays help keep nasal passages open.  Do not use nasal decongestants or antihistamines as these are generally only meant for short term use.  Long term use can have adverse impacts.
  • If you are s smoker, stop.

CPAP ImageSleep Apnea Therapies:

  • CPAP (continuous positive airway pressure) machines deliver air pressure through the use of a mask placed over the nose while sleeping and is often the mechanism used for moderate to severe cases of sleep apnea. CPAP is the most commonly used and reliable method in treatment of sleep apnea.  The most common issue with CPAP machines is comfort and many people give up on them due to this.  However with a bit of adjustment of the straps on the mask a comfortable yet secure fit can be accomplished. There are also a variety of differing masks available as well as humidifier systems for CPAP.  If you are using CPAP do not give up on using it instead call your physician as there are many ways to make usage of the systems more easily tolerated.
  • BiPAP (bilevel positive airway pressure) machines differ from CPAP in that they provide more pressure when inhaling and less when exhaling.  Some people find BiPAP machines to be more tolerable than CPAPS continuous air pressure.
  • EPAP (expiratory positive airway pressure) are small devices that are single-use and placed over each nostril before bed.  These devices allow air to move freely in but when exhaling air must go through a small valve and thus increases pressure in the airway and keeps it open.

Oral appliances:

Oral appliances are designed to keep a person’s throat open and are generally well tolerated for mild occurrences of obstructive sleep apnea.  Most of these work by shifting the lower jaw forward a bit during sleep which can relieve mild conditions.  You may have watched commercials or infomercials related to these types of devices which make claims of stopping snoring.  Some of the more effective brands are available through dentist offices where fit may be adjusted to reduce discomfort.  Dentists do have other options available as well and it can be a series of trying different mechanisms to find that which seems to work best with the least discomfort.

CPAP is much more reliable than oral appliances as these make sure proper breathing is taking place.

Surgery:

Surgery for sleep apnea is usually only considered of other mechanisms have failed in all cases except those where actual jaw structure may exist thus surgery necessary to alter the condition.

Surgical options:

  • A surgeon will remove tissue enlarging the airway known as uvulopalatopharyngoplasty through the nose and/or throat.  Tissue is removed from the rear of the mouth and top of the throat.  Tonsils and adenoids are often removed as well.  Effectiveness of the procedure is often disappointing in comparison to CPAP. A similar procedure uses radio frequency ablation to remove tissue from the back of the throat which is less intrusive.
  • Repositioning of a person’s jaw is another surgical procedure which enlarges space behind a person’s tongue and soft palate resulting in less obstruction.  The procedure is known as maxillomandibular advancement.
  • Surgical implants are another option where small plastic rods are implanted into the soft palate.
  • If other forms of treatments fail or the sleep apnea is life threatening creating a new air passage may be attempted.  A tracheostomy is a procedure where a metal or plastic tube is is used for breathing.  It is inserted in an opening created in a person’s neck.  During the daytime the opening is covered and at night uncovered.

Depending on the reasons why sleep apnea is occurring other surgical options such as deviated nasal septum or removing polyps, tonsils or adenoids might relieve sleep apnea.

BiPAP MachineOptions For Central or Complex Sleep Apnea:

Since central or complex sleep apnea are conditions where characteristics of the disorder are associated with other factors treatment of these contributing factors needs to be considered.

  • Possible central sleep apnea causes include neurological disorders impacting muscles or heart problems might need to be addressed to eliminate central sleep apnea.
  • Oxygen supplementation may help resolve central sleep apnea where a device is used to deliver oxygen to a person’s lungs.
  • CPAP (continuous positive airway pressure) as is used in obstructive sleep apnea may also provide relief in central sleep apnea cases.  In central sleep apnea it is more imperative to make sure the device is properly used and air pressure fine tuned.
  • BiPAP (bilevel positive airway pressure) also used in obstructive sleep apnea is again an option with central sleep apnea.
  • ASV (adaptive servo ventilation) is a newer airflow device.  Using a computer and smart technology this ASV devices learn your breathing pattern and stores the information.  When a person falls asleep the device uses air pressure to normalize the breathing pattern to prevent pauses in breathing. Currently ASV devices seem to be more successful in treatment of complex sleep apnea for many people.

New Technology:

AiringSince so many people whether healthy or enduring an illness that results in sleep apnea across the world live with this condition several new technologies are also in development.  One of the most interesting is called “Airing” which is a very small battery operated CPAP device.  Airing is a small device that is inserted into a person’s nostrils at bedtime and provides the benefits of CPAP without the associated mask and external delivery unit.  Technologies such as Airing will revolutionize home sleep apnea management.

Summary:

Sleep apnea is a serious condition which is often not diagnosed in multiple sclerosis patients.  Since quality of rest is such an important facet in respect to multiple sclerosis patients who think they may suffer from this disorder should seek treatment options as soon as possible.  Sleep apnea affects healthy people as well so as a multiple sclerosis patient one should not feel that exploring sleep apnea to be a frightening experience.  Quality of sleep is important to quality of life, reduction of fatigue and overall best outcomes in multiple sclerosis.

If you believe or your partner believes you may be experiencing sleep apnea consider setting up an appointment with your healthcare provider to discuss and evaluate your sleep.  If you do have sleep apnea getting the condition resolved can result in very big gains in respect to coping with multiple sclerosis.