Over the years, I have had the opportunity to interact with many men and women who have sleep disorders. The vast majority have obstructive sleep apnea (OSA). I have come to appreciate that men and women often differ in their perception of OSA and PAP (Positive-airway pressure) therapy. Many people (of both genders) are enthusiastic about treatment. Others are less so. I spend a lot of time in my clinic discussing PAP-alternatives for those patients who are apprehensive about the device.
“Doc, there’s no way I’m going to wear that thing.”
“You’re kidding, right? Isn’t CPAP for old, fat men?”
And so begins another Monday in sleep clinic. I get it. CPAP isn’t sexy – but neither is untreated sleep apnea. OSA prevalence continues to increase with an estimated prevalence of one billion people worldwide. We are learning more about OSA and other comorbid disease. We are beginning to understand that OSA is a chronic medical disorder that requires chronic treatment.
I agree – CPAP isn’t perfect but we still need to treat obstructive sleep apnea when it meets criteria for treatment. As women, we (in general) seem to fight the idea of having sleep apnea more than our husbands. We have a lot of negative associations with both the idea of having sleep apnea and with CPAP therapy in general. We often take it to mean that we are too fat or too old. Neither is necessarily true. Obstructive sleep apnea is repetitive collapse of the upper airway resulting in low oxygen levels and our brain waking up. It is not something we are doing on purpose – it is just the way our anatomy is. Can we change our habits to effect change on our anatomy? Yes, weight loss typically helps improve obstructive sleep apnea. Sleeping better will help us to lose weight. Is it reasonable to treat our sleep apnea WHILE we try to lose weight? Absolutely. A study in 2017 showed that PAP adherence in women is impacted by our relationships – the more supportive our spouse, the better our adherence. If our spouse is not supportive, we tend to abandon PAP therapy.
Treating obstructive sleep apnea does not always mean wearing a CPAP. There are many ways of treating OSA – dental appliance, weight loss, avoiding sedatives and alcohol, nasal EPAP therapy, hypoglossal nerve stimulation, and even surgery. The bottom line, though, is that we need to treat it somehow.
More data is showing us that as women, obstructive sleep apnea impacts us in different ways. According to a recent Harvard study, OSA is an independent risk factor for heart disease in women, but not men. Dr. Gabriela Roca’s group evaluated 1625 people who were free of heart disease at baseline and followed them for an average of fourteen years. They found gender-specific differences with respect to cardiovascular disease and sleep apnea. In women, sleep apnea was associated with a higher troponin level, signifying early heart injury. They also found an increased risk of heart failure, coronary artery disease, cardiac enlargement, and death in women with obstructive sleep apnea. This was a strong argument in favor of looking for OSA in women, who may present with more atypical symptoms and thus remain under-diagnosed.
Every year, there are more data associating poor sleep with poor outcomes – poor sleep is a risk factor for hypertension, diabetes, stroke, and heart disease. Poor sleep refers to both quantity of sleep as well as quality of sleep. We need adequate amounts of good, restorative sleep.
New data is also demonstrating that sleep is important for cognition. I had the opportunity to hear Dr. Charles Czeisler speak a few years ago at a sleep conference (AASM Sleep Medicine Trends 2013). He described an animal study that looked at how the brain changed during sleep. He asked us to imagine that our brain is like New York City – lots of tall buildings with alleys in between. All day long, people are tossing debris out of the windows and it is being cleared away by trucks in the alleys. During sleep, the buildings shrink and the alleys become wide – all of that debris is swept away. When we don’t have adequate sleep, the debris builds up. When they analyze that debris, it is beta amyloid, the substance that builds up in Alzheimer’s dementia. Sleep may play a pivotal role in cognition by clearing away this beta amyloid build-up.
Even those in the beauty industry recognize the importance of good sleep. Estee Lauder funded a study looking at skin quality in those who slept well and those who did not. They found that those who slept well appeared to be more youthful than those who were did not sleep well. Poor sleepers assessed their skin and facial appearance more negatively than good sleepers. They also had slower recovery from sun exposure. The study utilized objective measures to score skin aging – again, those who were poor sleepers showed increased signs of intrinsic skin aging such as fine lines, reduced elasticity, uneven pigmentation, and slackening of the skin.
For some, one of the most rewarding aspects of having a uterus is the ability to bear children. Obstructive sleep apnea influences even this sacred time of our lives. One recent study analyzed medical records of over 1.5 million pregnant women in the US National Perinatal Information Center database. They found that the risk of ICU admission was 174% higher in pregnant women with OSA compared to pregnant women without OSA. They also stayed in the hospital longer and had a significantly higher risk of serious complications such as cardiomyopathy (259%), hysterectomy (126%), congestive heart failure (263%) and pulmonary edema (406%).
The authors reasoned that since pregnancy is a window into future cardiovascular and metabolic health, it is prudent to seek an OSA diagnosis during pregnancy in order to potentially impact future health.
As we learn more, we recognize the increasing importance of treating this chronic disease. As sleep professionals, we need to offer our patients more treatment options and allow them to realize that we will still treat them even if they do not wish to be on PAP therapy. In our role as patient advocates, we must seek out all possible treatment options, including weight loss, even if the conversation is difficult.
So yes, treating sleep apnea and obtaining adequate sleep hours is important. We need to embrace the idea of treating sleep disorders just as we would treat any other disorder – diabetes, heart disease, or hypertension. Instead of taking a pill, we need to do something to effectively open the airway at night. If CPAP isn’t the right fit for your patient, please find something that is. This is too important to ignore simply because it seems unattractive or cumbersome. Let’s continue to partner with our patients to treat their sleep apnea by choosing a treatment modality that is both clinically effective and accepted by the patient.
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