Can Narcolepsy Cause Sleep Apnea ?

I am tall and thin. Even on Auto-PAP treatment I have moderate to severe apnea events (30 > AHI > 60) during REM almost exclusively and much more so when sleeping on my back than tummy. After being on APAP treatment for more than 90 days I still have significant daytime grogginess, high blood pressure, and significant body aches (like always being attacked by a virus feeling). The body aches may be due to a neuropathy (my mom has Charcot-Marie-Tooth, hereditary, and I have some mild symptoms of that, like numb spots on my left foot). DeltaDave points out sleep onset REM when I post charts, and I can confirm that sleep-onset REM almost always occurs now that I have about 45 days of data, but that's seen with a Zeo (not a medical device) which is known to be a bit "iffy" in distinguishing between Wake, Light and REM particularly at sleep onset, but it suggests sleep-onset REM exists because it is doing so fairly consistently with me. I do not have cataplexy (that I'm aware of), however...

I have a theory that my base problem is actually very mild narcolepsy which causes sufficient/significant cataplexy during REM, thus my airway collapses, thus I have apnea events, thus I'm diagnosed with "Sleep Apnea". The positional aspect is when on my tummy my airway tends to remain open (falls open), but on my back it collapses (falls closed).

I have booked an appointment with my sleep neurologist for Tuesday to discuss this.

Thoughts?

I could not find any articles that note a correlation between narcolepsy and sleep apnea (especially during REM sleep). However, it is quite possible the atonia (lack of muscle tone) during REM sleep might be so intensified that it would cause more problems for you, if you have a mild form of narcolepsy. You are definitely going the right direction and scheduling an appointment with a neurologist who specializes in sleep disorders.

Do keep us posted. I would be interested to see what your doctor thinks about this. And we certainly wish you well as you struggle to find restful sleep.

I thought that it was not unusual for folks with narcolepsy to also have OSA, that is, they can be comorbid.

I'm not sure I understand your theory about how narcolepsy can cause OSA. Everyone has atonia during REM, and lots of people have worse OSA in REM and/or on their back. What role would cataplexy have in this? I thought cataplexy was muscle weakness in response to emotions. Even if cataplexy can occur in sleep, how much worse can it be than atonia?

Maybe you are right; I just have never heard of this.

SleepingUgly wrote: Even if cataplexy can occur in sleep, how much worse can it be than atonia?

I probably used the wrong word. Atonia may be better.

lots of people have worse OSA in REM

Yes, many do, not all, some more than others so perhaps it's a matter of degree. It's pretty clear here that there are numerous sub-groups of apnea patients (differing causes) including ones much like me, who has very REM specific OSA. I don't have many events outside of REM. I'm asking, or perhaps suggesting, that if a patient has mild narcolepsy they may have such atonia during REM that it causes the apneas. I am treating the REM OSA, however the reasons I went to the doctor persist... Hence, I am suspicious that OSA is a symptom of a different underlying cause.

Ergo, I'm starting to think I'm a narcolepsy patient and the narcolepsy has caused my OSA problem.

In the end, it may not matter. The result may be the same... APAP + something to keep me alert during the day.

MaxDarkside wrote: I'm asking, or perhaps suggesting, that if a patient has mild narcolepsy they may have such atonia during REM that it causes the apneas.

But even people without narcolepsy have atonia during REM.

I am treating the REM OSA, however the reasons I went to the doctor persist... Hence, I am suspicious that OSA is a symptom of a different underlying cause. Ergo, I'm starting to think I'm a narcolepsy patient and the narcolepsy has caused my OSA problem.

Why aren't you thinking any of the following thoughts that I'd be thinking if I were you :

(1) Why is my AHI still so high even with CPAP? (I couldn't understand what your AHI was from your post, but I understood that it's high).
(2) How can I expect not to be tired if I'm still having so many respiratory events that my AHI is so high?
(3) If I got control of my AHI/OSA, will that address my EDS, or does my EDS have another potential etiology in narcolepsy? In other words, is my EDS caused by OSA or by narcolepsy or both?

SleepingUgly wrote:But even people without narcolepsy have atonia during REM.

Is the self paralysis everyone (normally) experiences during REM manifest atonia? If yes, then I would say "All people have atonia during REM". I'm saying / asking if it is possible / likely that narcoleptics have MORE atonia to the degree they manifest OSA for that reason.

(1) Why is my AHI still so high even with CPAP? (I couldn't understand what your AHI was from your post, but I understood that it's high).

My AHI for the night is about 1-2. Pretty good!

(2) How can I expect not to be tired if I'm still having so many respiratory events that my AHI is so high?

My real question is why do I still feel really groggy when I *don't* have many events and why are most all my OSA events during REM?

(3) If I got control of my AHI/OSA, will that address my EDS, or does my EDS have another potential etiology in narcolepsy? In other words, is my EDS caused by OSA or by narcolepsy or both?

Yabbut, I have control of my AHI/OSA, except during REM and thus you got this on the nose... "does my EDS have another potential etiology in narcolepsy?"

Narcolepsy => OSA => EDS
Narcolepsy => EDS

Thus, since EDS persists, fixing OSA does not fix my true cause of EDS.

I just went through some of my data and actually, to correct myself, most of my apnea clusters appear when starting or ending REM. The transition seems to be point I have problems.

Thanks,

Well, as SleepingUgly pointed out this is NOT a feature of narcolepsy:

MaxDarkside wrote: Even on Auto-PAP treatment I have moderate to severe apnea events (30 > AHI > 60) during REM almost exclusively and much more so when sleeping on my back than tummy.

It's likely a feature of undertreated apnea or compSAS (iatrogenic apneas caused by the machine). And EDS is associated with either of those two.

-SWS wrote:It's likely a feature of undertreated apnea or compSAS (iatrogenic apneas caused by the machine). And EDS is associated with either of those two.

Could be, but I have very few "centrals" as classified by the ResMed AutoSet, so that would leave "under treated" in your likelihoods. I did do a better job of busting up my clusters of apneas by raising my lower APAP limit, tho the EDS / grogginess remains, combined with the *suspected* sleep onset REM (hard to tell if that is valid w/o a MSLT) which suggests another cause and the reason I'm thinking about all this, coming up with theories and going to my neurologist on Tuesday to discuss.

Well, if you research diagnostic criteria, you'll find that neither of those two conditions happens to be a diagnostic correlate for the other.

Apnea is somewhat prevalent in the general population. Narcolepsy is comparatively rare. And, of course, having both conditions would be even more rare. EDS is associated with all of the above. Good luck with your upcoming neuro visit!

How do you reconcile this statement:

MaxDarkside wrote:My AHI for the night is about 1-2.

With this one:

MaxDarkside wrote: Even on Auto-PAP treatment I have moderate to severe apnea events (30 > AHI > 60) during REM almost exclusively and much more so when sleeping on my back than tummy.

?

An APAP can't differentiate when you're in REM and when you're not, so how do you know that you have an AHI of (what does that say? 30-60?) in REM?

What is your APAP set to?

The problem is that if you go into an MSLT with this poorly treated OSA, when you have sleep onset REM episodes, it won't be clear if it's due to undertreated OSA or narcolepsy.

SleepingUgly wrote:How do you reconcile this statement:

MaxDarkside wrote:My AHI for the night is about 1-2.

With this one:

MaxDarkside wrote: Even on Auto-PAP treatment I have moderate to severe apnea events (30 > AHI > 60) during REM almost exclusively and much more so when sleeping on my back than tummy.

You will note my reference to high AHI was conditional: "during REM"

An APAP can't differentiate when you're in REM and when you're not, so how do you know that you have an AHI of (what does that say? 30-60?) in REM?

I can see when I'm in REM. I have data correlated from multiple sources.

What is your APAP set to?

about 8-15 cm H2O

The problem is that if you go into an MSLT with this poorly treated OSA, when you have sleep onset REM episodes, it won't be clear if it's due to undertreated OSA or narcolepsy.

My OSA is pretty well treated overall. My neurologist will likely say a nightly 1-2 AHI is pretty durn good. I don't seem to have apnea events when I enter sleep. It's in the later REM periods.

MaxDarkside wrote:My OSA is pretty well treated overall. My neurologist will likely say a nightly 1-2 AHI is pretty durn good. I don't seem to have apnea events when I enter sleep. It's in the later REM periods.

Explain to your neurologist that the mean is not the best measure of central tendency in the presence of outliers.

-SWS wrote:Apnea is somewhat prevalent in the general population. Narcolepsy is comparatively rare.

Yes, and one must ponder the rarity and thus the likelihood I would have it, which is probably quite low, esp. if we were talking about apnea events alone. The probability of having Charcot-Marie-Tooth is 0.0004, but my mom has it, and I likely too. The probability of having Hypertrophic Cardiomyopathy is 0.0017 in a random sample of 4111 young adults, but my wife has it. The probability of having POTS is probably 0.0017 but my wife has that too. Having HCM and POTS together is 2.894672828995378e-6, but alas I cannot tell her she's not afflicted because it is unlikely (as she drinks volumes of brine to maintain a pulse pressure above the teens).

So yes, you are right, but ... I'm not sure why I have the EDS (actually, grogginess) and I dream immediately as I fall asleep, and someone noticed that a slightly reliable device was consistently noting sleep onset REM and I'm quite thin and my neurologist does not know why I have sleep apnea (pretty much a quote) and I do know my OSA is pretty well treated now, but more acute during REM, which I find curious. And so I ask questions of you good folks because you have so much more time with sleep disorders than I.

It gives me better ideas in how to formulate my discussion with my sleep neurologist. Thank you.

SleepingUgly wrote:Explain to your neurologist that the mean is not the best measure of central tendency in the presence of outliers.

I know precisely what you mean. It is how I make my living. He may not be aware, I hope he does not care, actually, but sits back and takes a look at the big picture to sense what is going on, or not.

Of course, my question is "Can Narcolepsy Cause Sleep Apnea ?" and what I've heard so far is:

1) Yes, it is possible
2) But It is not likely.