Cognitive impairment - Could it be non-optimal CPAP?

[Marcman]

Thanks, everybody! It's awesome to have suggestions from you guys!

I've seen the psychiatrist twice

Has your psychiatrist made a diagnosis yet and if not what is her opinion concerning your symptoms?

After the first visit, she said that I had many ADHD-like symptoms but said that I don't qualify for an ADHD diagnosis, because I didn't have childhood symptoms (my parents filled out a questionnaire and said no to every single question about ADHD symptoms as I was a very good student, rarely got in trouble, and if anything, was on the shy side rather than impulsive and hyperactive). She decided to label it as "ADHD otherwise unspecified", which apparently says that I have ADHD symptoms but it doesn't match the diagnostic criteria for ADHD. She then speculated that the sleep apnea was a likely cause and my CPAP therapy probably wasn't effective enough for me. Before the second visit, she had me try to go to bed every night at an earlier and more consistent time. My wife and I are pretty bad about consistent bedtime as we tend to get caught up with watching TV and doing chores like loading the dishwasher. Because the doctor suggested it, we tried a little harder and did fairly well at getting 7+ hours of sleep. Symptoms didn't get better. On the second visit, she did a bunch of cognitive assessment tests and this is where she discovered that I did super well on all the tests except for 1, a delayed recall memory test in the MoCA, in which I did very poorly. I think this further convinced her that this was a sleep apnea issue. At this point, she basically politely said that this was now outside her realm of expertise and that it was best to stop seeing her and instead go back to the sleep doctor and explore whether the apnea was really being treated well enough. I've faxed a bunch of the info that I posted here to my sleep doctor a few days ago and haven't heard back from him yet -- this is confirming a feeling that I had that this doctor is mainly interested in handing out CPAP machines. I might give his office a call and schedule an appointment -- or I might just try to handle this myself, as I suspect it will be quicker, cheaper, and possibly more effective (because I care more about how I feel more than any doctor could).

By the way, on a tangent, we found what is probably our first bed bug yesterday in a "bed bug interceptor" trap that we placed under our bed posts. Ugh. These traps were inspired by bites that I have been finding on my arms. I've given only a little thought to the idea that the bed bugs could be contributing to the problem by disrupting sleep or causing allergic reactions in my body.

Last night, I did a nasal rinse and took Zyrtec and Nasonex in an effort to keep my nose as unobstructed as possible and I slept with a Chin Up strip (one of the white ones) to try to keep my mouth closed. I don't think it was effective. My wife and I noticed air sputtering out through my lips and a quick glance at the stats in ResScan suggests that the leaks are still a problem. Median=0.0; 95%=22.8; Max=34.8. AHI was 1.2 (almost entirely centrals), but like some of you have said, I don't think I can trust the AHI numbers if I'm leaking a lot. I have a PAPcap on order, but I have a feeling that devices that encourage me to keep my mouth closed are not going to be effective for me as I was a big-time drooler before I had CPAP. I am now wondering if I should just pop on over to SleepQuest and have them fit me for a full face mask... (I have no idea which one to pick, but I guess I can just try a bunch on and see which one seems to fit my face the best?). What do you all think?

[DoriC]

Resmed Mirage Quattro FF,Resmed Quattro FX, Resmed UltraMirageFF, FP 431, and Hybrid masks are all pretty popular ones. Make sure you get fitted properly, correct size is really important.

[SleepingUgly]

If you can breathe through your nose, try to keep your mouth shut. You have a Papcap on order. If that doesn't work, try the strapping technique of a self-adhering ace around your mouth (search for "strapping") in this forum.

You are in San Jose. Can you get yourself to Stanford?

[Marcman]

Hi folks,

I have some more interesting data. So after SleepingUgly's suggestion, I went out to Walgreens and picked up one of those 2" Ace bandages (I got the kind with the clips because I thought it would be reusable; maybe this was a mistake because the clips are pretty annoying how they fall off so easily, although some duct tape seems to be doing the trick for now).

Anyway, I used the Ace bandage last night. I looped it over my mouth and then I had a lot of excess so I wrapped it around my jaw a few times pretty tight, kind of like a chin strap. I looked like a mummy. I went to bed like that, but after a while I just found it annoying and I wasn't sleeping well - I don't know whether I slept or not. I got up and took off the improvised chin strap and left the loop that went over my mouth, which seemed a lot more comfortable. I glanced quickly at the stats on the machine and noticed that the leak said 0.0. Anyway I slept the rest of the night with just the loop over my mouth and I think I caught myself lip fluttering a few times.

In the morning, I fired up ResScan and saw this graph:



It's super interesting to me that there are two pretty distinct segments of time, which I have to imagine correspond to whether I was using my Ace chin strap or not.

While I was wearing the "chin strap", leaks were super low, which is great. However, obstructive apneas and hypopneas were pretty crazy (and no central apneas). When the "chin strap" was off, things look more like my regular pattern of periods of high leaks and "central apneas" but no obstructive apneas.

So my theory is that without a chin strap, I leak through my mouth and the central apneas reported by the machine are likely to be garbage, the result of the machine getting confused by the leaks. When something keeps my mouth shut, and I seem to need something pretty strong to keep my mouth shut, the leaks go away but it's concerning that the apneas and hypopneas get pretty bad. I am hoping that the apneas and hypopneas happened because I was overly aggressive with the "chin strap" and maybe it slipped down to my neck area and constricted my airway in some way. If that is the case, then maybe a proper chin strap would work. Otherwise it could be that my CPAP treatment is not getting rid of the apneas and hypopneas and all the chin strap is doing is getting rid of the leaks so that the machine can measure them. In that case, I don't know what the next step would be -- higher pressure? BiPAP? Surgery?

I made an appointment with my DME for Wednesday to talk about chin straps and full face masks. I'll show them this data and hopefully, they'll be able to recognize the patterns and tell me what it is.

[SleepingUgly]

I use the Walgreen's 2" self-adhering bandage (not the one with the clips). I wrap it around my mouth twice, so two full loops around the back of the neck and mouth. I pin it with a small safety pin in back. It does loosen over time, and when it does, I will get lip flutters. When it's not loose, no lip flutters. Leak is low. My only complaint is that it leaves an imprint of the bandage on my face that lasts for HOURS on my not-so-elastic skin. You are younger, and you may have some razor stubble so may hide it better.

I would try that before moving to a full face mask, and try the papcap that you have on order. (BTW, at least one respected authority in the field does not feel that full face masks are effective.)

[rested gal]

The poster nicknamed split_city raised some interesting questions on page 6 of this topic:

Jul 10, 2007 subject: You can't die from Sleep Apnea

split_city wrote: "So there are studies out there which is looking at the effect of hypoxia. I have no doubt there are other studies which look at the effect of hypoxia on cell death in mice.

The question is, does hypoxia cause irreversible damage to cells in OSA patients? If so, how does this effect cognitive function?"


I think many of us who are using CPAP treatment have wondered, "If damage has been done to my brain cells during so many untreated years of not getting enough oxygen while I slept, how much of the damage can be repaired by consistent CPAP treatment now?"


There were some interesting links about the possibility of residual damage in this old topic:

Jul 21, 2005 subject: Brain Fog topic started by DCTom
viewtopic.php?p=29599

One of the links (which unfortunately no longer works) was to this:

Editorial in Journal of Sleep 2004 titled "Residual Sleepiness in Patients with Optimally Treated Sleep Apnea: a Case for Hypoxia-Induced Oxidative Brain Injury"

Excerpt from the editorial:

"Thirdly, chronic exposure to the features of OSA, such as repetitive intermittent hypoxia, arousals from sleep, or both, could cause neuronal dysfunction. The increased cell apoptosis, which occurs in the hippocampus and cortex of rats chronically exposed to intermittent hypoxia, supports this latter suggestion.[9] Indeed, in these animals, the neuronal dysfunction has been shown to be in the C1A hippocampal region, an area known to be associated with spatial memory and susceptible to hypoxic damage. Interestingly, in this study, the impaired ability to perform spatial memory tasks was only partially reversed after 14 days of normoxia, suggesting residual damage.
In patients with OSA, focal lesions have been detected in the left hippocampus[10] and in more diffuse areas of the brain[11]; as yet, these changes have not been linked to functional consequences. Further research will doubtless explore these tantalizing links between changesin brain morphology and the neurocognitive functional consequences."

_______________


A link, which does still work (so far):


High Altitude Study
(There are little forward/backward arrows above the article to "turn" pages.) Below is an excerpt from page 439:

"Interestingly, a few studies have even reported that some of the changes in performance after exposures to extreme altitudes persist for up to a year or longer after return to lower altitudes, although much debate surrounds this issue (Bahrke and Shukitt-Hale, 1993)."



A link which has gone "poof" --
"Cause or Effect? Gray Matter Loss in OSA Patients" Article from Pulmonary Reviews


From the article:
LOS ANGELES — The brains of patients with obstructive sleep apnea (OSA) appear to have decreased amounts of cerebral gray matter, researchers have found.[1] Whether the loss of gray matter contributes to OSA or vice versa is not known, but reduced gray matter may perpetuate the dysfunction of upper airway muscles.
Investigators from the Department of Neurobiology at the University of California in Los Angeles used magnetic resonance imaging (MRI) to compare the brain morphologies of 21 men who had documented OSA and 21 healthy controls. The control group also underwent sleep studies to verify the presence or absence of breathing disturbances.
The MRI scans were analyzed using morphometry designed to detect regional gray matter volume changes. Volume measurements were calculated for white matter, gray matter, the two combined, and cerebrospinal fluid.

DIFFERENCES IN GRAY MATTER

The OSA patients had significantly less gray matter than did the control group. The extent of gray matter loss increased with the severity of OSA. Differences in gray matter between the two groups varied from 2% to 18%, depending on which region of the brain was examined.
There were no between-group differences in white matter or cerebrospinal fluid. Because of the decrease in gray matter in the OSA patients, however, the ratio of total gray-to-white matter volume was significantly greater in the control group. In this group, but not in the OSA patients, the ratio of gray-to-white matter volume declined significantly with age.

WHICH CAME FIRST?

According to the researchers, the results of this study suggest two possibilities. The first is that gray matter loss is a consequence of apnea, and the second, that preexisting gray matter abnormalities contribute to the emergence or maintenance of OSA.[1] Damage to certain areas of the brain may play a role in the cognitive deficits that sometimes accompany OSA.
The investigators noted that at least some changes in the brains of patients with OSA may have resulted from the hypoxia that, along with hypercapnia and elevated blood pressure, occurs during episodes of OSA. Peripheral tissue oxygen saturation during apneic episodes in severe OSA can fall to 70% or less. Repeated episodes of hypoxia can damage gray matter, and patients with OSA have reduced cerebral blood flow.[1]
Conversely, reduced regional gray matter may have preceded OSA and contributed to its development. Reductions in gray matter can be congenital or acquired. This study found gray matter loss with age in the control group but not the OSA group, suggesting that damage to gray matter occurs early in OSA patients. Additionally, in a number of medical conditions, cerebellar damage results in a high incidence of sleep-disordered breathing.
We are left with the question of whether brain changes are a result of OSA or whether they precede it. In an editorial, David Gozal, MD, asked, “Is it the chicken or is it the egg?”[2] For now, he wrote, we can only speculate.

—Gale Jurasek

References
1. Macey PM, Henderson LA, Macey KE, et al. Brain morphology associated with obstructive sleep apnea. Am J Respir Crit Care Med. 2002;166:1382-1387.
2. Gozal D. The brain in sleep-disordered breathing: is it the chicken or is it the egg? Am J Respir Crit Care Med. 2002;166:1305-1306.

[rested gal]

Oh one more thing. I went to an ENT a few months ago and he said I had a deviated septum. I don't know if he qualified it as minor, major, etc. but I recall that he told me about the surgery for correcting it but didn't really push it. He told me about how the recovery is uncomfortable and then said it was up to me and I could do it if I wanted to and then sent me on my way with some Nasonex samples. I took this to mean that he thought it was a minor case and probably wasn't affecting me too much, but maybe he's just polite and doesn't want to be pushy. It's possible that a deviated septum could be contributing to mouth breathing and mouth breathing is reducing the effectiveness of the CPAP in which case I guess I should either get the surgery or just use a full-face mask.

Sounds like your ENT was a good one -- and an ethical one. Not pushing you into surgery for a deviated septum that he possibly saw as not tooo much of a problem.

There was an interesting video from Dr. Sy Park (ENT) called: "The Deviated Septum Myth"
http://www.doubletwist.com/podcasts/bre ... 7yWm0ujtq/

[Marcman]

Short update.

I finally had a night with really good leak numbers. Even the max number (1.2) was in the single digits (possibly for the first time!).

What did it? Ace bandage wrapped head to chin and over my mouth, Breathe Right nasal strip, saline nasal rinse (NeilMed SinuRinse bottle) and Zyrtec before going to sleep, and slept downstairs on the couch (started on the recliner but couldn't fall asleep there so I moved to the couch; I didn't sleep in bed so I could spare my wife from all the fiddling I thought I might be doing). Leak numbers were excellent. AHI was 2.8 with 0.9 obstructive, 1.6 central, and 0.3 hypopnea.



The biggest problem was that I only used the CPAP for 5 and half hours and because it took me a while to fall asleep, I probably slept less than 5 hours. I woke up around 5 am and had trouble falling back asleep, mainly I think because I felt like I maybe wasn't getting enough air through my nose. So far I feel pretty good this morning - I was up quite early and tackled some simple tasks that I otherwise might've procrastinated on (e.g.: getting my email inbox to zero). I don't know if I feel good because of the lack of leaks or because sometimes I get a burst of energy when I don't sleep as much (anyone else experience this? It's sort of like a second wind after an all-nighter).

I wonder if my nose is obstructed enough (e.g.: by deviated septum) that I really can't get as much air as I need through it. That might be why before CPAP I was a drooler and with CPAP, I seem to be prone to mouth leakage unless I wrap myself up like a mummy. Of course if I can't get good air through my nose and I'm covering my mouth, that is actually pretty bad. I'm going to the DME today. I told them over email about my mouth breathing and they said let's start with a chin strap, but now I'm wondering if I should insist on the full face mask? I'm also thinking about going to another ENT and getting a second opinion on whether my deviated septum is severe enough to be affecting my nasal breathing.

Slight tangent: I wonder if I feel better when I don't sleep as much, because I'm actually oxygen-deprived when I sleep...

[Marcman]

Slept with a borrowed Quattro FX last night. It felt like it was leaking numerous times throughout the night, much worse than the Swift FX, but I was very surprised when I looked at the data that my maximum leak # was LOWER than it typically was with the Swift FX without covering my mouth at all. Does that make sense? Could I have been leaking much more through my mouth then one might leak around the edges of a FFM?

Graph:



Hopefully it's not the placebo effect, but I feel somewhat better today.

[BlackSpinner]

Could I have been leaking much more through my mouth then one might leak around the edges of a FFM?

It depends on how big your mouth is LOL. I suspect it is a lot bigger then the edges of the mask.

[Bugged about sleep labs]

Marcman:
You mentioned you have bed bugs. Sorry, but I want to advise you to never mention that fact to a sleep doctor or a sleep lab. I was all set for my lab study but when I told them I had bed bugs and the precautions I would take, the sleep lab refused to treat me. My prescribing doctor intervened but they still refused. It was terrible and unethical but I was never allowed to go for the lab study. My prescribing doctor told me to go to another sleep lab and not mention bed bugs.

Since the first lab I went to had no procedures or policies in place for dealing with bed bugs except to say they cleaned the room and washed the sheets in hot water (hotels wash sheets and clean their rooms but people can get bed bugs from hotels) I certainly wonder about the sleep lab industry and bed bugs. I wish I could sign my name and contact you. I feel bad about the bed bugs but worse about how the sleep lab handled it. Everyone going for a sleep study should ask their sleep lab about bed bugs and consider that they might be exposed to them in the lab, just as one might be at a hotel. Patients with bed bugs might need to lie about it in order to be allowed to have the in-lab test.