Are You Sleeping With the Enemy? [draft for comment]

[SleepGuy]

Several people have asked me to put together an article that includes some of the stats and analysis on sleep apnea that I've posted on various threads lately and submit it for Our Collective Wisdom.

Here's a draft and I'd like to invite feedback/comments before submitting it to the powers that be.

Are You Sleeping with the Enemy?

By SleepGuy
SleepGuy@comcast.net

If an intruder tried to suffocate you with a pillow hundreds of times a night, you’d call the police. In the case of sleep apnea, the airway blocks off and victims stop breathing for up to several minutes--but the victim has no idea it's even happening. “The body, in essence, is being assaulted by the damage done from intermittent lack of oxygen to the heart, brain and other important organ systems, and yet such an assault goes unreported. That is, patients who have these symptoms don't always have their sleep apnea corrected. Perhaps in the light of a metaphor such as the one of being assaulted by our own sleep disorder, people would take more care of their sleep. Their hearts will thank them,” says Ralph Downey III, PhD, of the Sleep Disorders Center at Loma Linda University Medical Center in Loma Linda, Calif.

Truth be told, sleep apnea may well be the most significant, costly, easily treated, and least understood public health issue facing our nation. The most recent studies predict that between 50 and 65 million Americans are at “high risk” for having sleep apnea. And very few of them have the slightest idea what sleep apnea is, much less that it may be affecting their lives in profound ways.

The Basics
Apnea is the medical term for “stopping breathing.” Sleep apnea is the temporary cessation of breathing during sleep, lasting for ten seconds up to minutes in length, depriving the body of oxygen. At some point the body arouses just enough to resume breathing and disrupt sleep, but usually not enough to awaken the individual. As a result, most people suffering from sleep apnea are not aware of their condition. In the most common type, obstructive sleep apnea (OSA), the airway blocks off when the tongue and/or other soft tissues in the throat relax and the individual simply stops breathing, sometimes for several minutes. This sequence can be repeated hundreds of times a night.

Apart from disrupting normal sleep patterns, sleep apnea wreaks havoc on the victim's body due to oxygen deprivation and physiological response patterns that occur during apnea events. There is no physiological signal stronger than oxygen deprivation to the brain. When blood oxygen levels are low, the body shunts blood from any and all organs, including the heart, to be sure the brain gets all available oxygen. On top of that, the sympathetic nervous system kicks in and releases a tremendous flood of stimulants and stress hormones, such as epinephrine (adrenaline) and cortisol, resulting in the well-known "fight or flight" response to danger.

Suppose somebody were to sneak up on you in the dark and lunge at you when you least expect it. Your heart races, the endocrine system instantly pumps out inordinately powerful stimulants. Sleep apnea victims are constantly confronted with a similar phenomenon and the accompanying red alert, each time their oxygen levels drop to a certain level. Another cruel twist happens when blood oxygen levels hover just above the critical desaturation level, getting just enough oxygen on board to avoid the arousal but not enough to provide the oxygenation that the body needs to stay healthy. The desaturation graph is remarkable for a very precipitous drop around the mid to upper eighty percent range for most people with sleep apnea.

Repetitive apneic events disrupt the normal physiologic interactions between sleep and the cardiovascular system. Sleep fragmentation, with its accompanying increased sympathetic activation triggers vascular endothelial dysfunction, increased oxidative stress, inflammation, increased platelet aggregability, metabolic dysregulation and undoubtedly helps initiate and accelerate the progression of cardiac and vascular disease. Persuasive data implicate sleep apnea in the development of hypertension, and sleep apnea contribute to cardiac ischemia, congestive heart failure, cardiac arrhythmias, and cerebrovascular disease and stroke.

At least if you’ve been attacked by a mugger you know to avoid ever going down that dark alley again. Sleep apnea, conversely, does not tip its hand. The victim’s conscious mind has virtually no recollection of the hundreds of assaults occurring during sleep every night.

It should not be surprising that common symptoms of sleep apnea include things like loud snoring and a gasping or snorting sound, high levels of daytime fatigue, irritability, depression, malaise, loss of productivity and work performance, extreme mental and physical exhaustion, loss of judgment, etc.

The Astounding Prevalence of Sleep Apnea in America
The numbers are shocking. The most recent studies have shown that one in four adults in the United States (31% of all men and 21% of all women over 18) is at “high risk” for OSA, based on analysis of the National Sleep Foundation’s 2005 Sleep in America survey. Another recent study showed that one third of all people over 18 (who visit a primary care doctor) are at “high risk” for sleep apnea. Based on the 2000 Census, that means that between 50 and 65 million Americans likely suffer from sleep apnea. This is far higher that previous estimates that projected that between 10 and 18 million Americans have sleep apnea. Increasing awareness of sleep apnea and improved survey screening tools, along with an aging U.S. population, seem to be factors in the increase in OSA prevalence estimates.

The Unacceptable Human and Economic Toll
According to the National Commission of Sleep Disorders Research, 38,000 cardiovascular deaths a year in the United States are directly attributable to sleep apnea. On top of that, sleep apnea is associated with a large number of serious, co-morbid medical and psychological conditions, such as hypertension, abnormal heart rhythm, sleep deprivation, stroke, heart disease, diabetes, depression, memory loss, poor judgment, and change in personality. As a result, undiagnosed and untreated sleep apnea victims are significant consumers of healthcare services.

In Canada, sleep apnea victims were shown to consume 23 to 50% more medical services in the five years prior to diagnosis than control subjects, with hypertension and cardiovascular disease accounting for the majority of increased costs. A recent study from Israel also showed that healthcare utilization was 1.7-fold higher by sleep apnea patients compared to the control group, with 25% of the sleep apnea patients who consumed the most resources accounting for 70% of the total healthcare expenditures. Other studies have demonstrated that successful sleep apnea treatment results in significant improvement in co-morbid conditions, including specifically cardiovascular disease, hypertension, diabetes, stroke, and depression.

Cardiovascular disease is the most significant killer in the United States, resulting in over 685,000 fatalities and $40.4 billion in healthcare costs annually. Hypertension healthcare costs in the United States are approximately $19 billion. While it is not known what percentage of all cardiovascular and hypertension healthcare costs is attributable to untreated sleep apnea, in light of the fact that between 50 and 65 million Americans are at high risk for the disease, it stands to reason that undiagnosed and untreated sleep apnea account for hundreds of millions—perhaps billions—of healthcare dollars spent treating conditions that could be more effectively and far more economically treated as a sleep disorder. The human value in savings of physical pain and mental anguish associated with invasive procedures, surgeries, and chronic disease and death cannot be quantified.

Collateral Impacts
Collateral impacts arising from 50 to 65 million clinically sleep-deprived people in the United States are almost incalculable. One report focusing on highway safety impacts from sleep apnea concluded that more than 800,000 sleep-apnea related highway accidents occurred in 2000, resulting in 1,400 fatalities and costing nearly $16 billion. If the same analysis were performed today using the new, much higher sleep apnea prevalence rates, the highway safety impacts would probably be twofold higher. Because extreme daytime exhaustion is prevalent among OSA victims, sleep apnea-related losses due to worker productivity, industrial accidents, clerical mistakes, sick leave, and so forth would be almost impossible to calculate but given the numbers no doubt amount to the billions of dollars annually. On top of this, the personal quality of life impacts—depression, personality changes, lack of judgment, irritability, utter exhaustion—cannot possibly be measured in economic terms.

Simple, Economic Treatment
The best news in sleep apnea is that it is a condition that is easily and economically treated. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for obstructive sleep apnea and has been proven to be highly effective in treating sleep apnea and improving a number of co-morbid conditions. CPAP therapy consists of a ventilatory device that applies positive airway pressure at a constant, continuous pressure to help keep the airway open, allowing the patient to breathe normally during sleep.

Where to Go from Here
Perhaps the biggest challenge in addressing the sleep apnea health crisis is lack of public awareness (including many doctors). Just to put this into context, 13,658 Americans died from AIDS in 2003 while 38,000 died from cardiovascular disease related directly to sleep apnea. Yet while virtually every teenager knows about AIDS virtually none of the 50 million Americans plagued by sleep apnea have any idea that a treatable sleep disorder is impacting every aspect of their lives. At the same time a little awareness on the part of the patient or his or her doctor is all that it takes for treatment to start and the suffering to end.

Unfortunately, a large number of doctors are still not very familiar with sleep apnea or its treatment. An excellent place to start (both for doctors and for individuals) is to fill out a one-page, ten question survey called the “Berlin Questionnaire” that is widely available on the Internet (http://www.pur-sleep.com/content/?id=30). This questionnaire is simple, fast, and is highly predictive of sleep apnea—the positive predictive value of the survey for people scoring as “high risk” is 89%. Sleep apnea victims often have to work hard to convince their doctor (or insurance company) to refer them for a sleep study, so a "high risk" showing on the Berlin Questionnaire might be enough to convince them to move forward with further tests. If people are not satisfied with their medical care they should get a second opinion, preferably from a sleep disorder specialist. A number of overnight screening assessment tools are also available. A formal sleep study is necessary, however, to diagnose sleep apnea and obtain CPAP treatment.

*******************
Individuals may freely use this article for any non-commercial purpose. Anyone may contact the author for further information, including citations and references to source materials.

SleepGuy@comcast.net



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CPAPopedia Keywords Contained In This Post (Click For Definition): news, CPAP

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[Mile High Sleeper]

Looks good. Amazing statistics.
A couple of typos in the paragraph "according to..."

[drbandage]

A man of ACTION with a talent for word-smithing.

You have a LOT to contribute, SleepGuy. Color me very, very impressed.

Thank you and I hope your karma comes back to you a thousand times over.

drB

[bookwrm63]

Excellent, SleepGuy. It is clear and to the point. With your permission, I will print this up to use for the interview next month. Thanks!

Mary

[Slinky]

EXCELLENT!!! Great job, thank you!

Just nit-picking here:

At that point the body wakes up just enough to resume breathing and disrupt sleep, but usually not enough to awaken the individual.

I would suggest:

At that point the body *rouses (*or arouses, which?) just enough to resume breathing and disrupt sleep, but not usually enough to awaken the individual.

... sleep deprivation, stroke, hearth disease, diabetes, ...

Just a spelling correction here:

... heart disease, ....

[SleepGuy]

Thanks for the feedback. I have edited the text a bit and corrected the errors pointed out so far! Please don't be shy about nitpicking here! And anyone is free to use this text for any purpose they want--please do! That's why I wrote it!

[Slinky]

What are your thoughts on adding "exhaustion" or equivalent to:

On top of this, the personal quality of life impacts—depression, personality changes, lack of judgment, irritability, etc.—cannot possibly be measured in economic terms.

After all, for many of us, that was our first and primary complaint. We were always so tired, so dragged out, no matter how many hours we "slept". Many of us experienced almost total exhaustion.

Just a thought.

I really, really like this article, SleepGuy, and think that it would be a great flyer to pass around, submit to newspapers, doctor's, etc.

[roster]

The most recent studies predict that between 50 and 65 million Americans (one third of all men and one fifth of all women) are at “high risk” for having sleep apnea.

This is from the National Sleep Foundation's telephone poll. I bet the poll has understated the problem.

Before I was diagnosed and started cpap therapy, I was so tired and irritable that I always hung up on pollsters. They were missing a large group of us in the poll!

[Rabid1]

SleepGuy,

Tremendous job!!

I will be sending a copy to my parents.

Rick

[XXX]

I POSTED A REPLY TO AN EARLIER DRAFT ON THE ORIGINAL THREAD; IT IS ATTACHED BELOW. Auricula

XXX
Guest

Posted: Fri Jan 26, 2007 5:47 pm Post subject: New version of Free Money, Come and Get It!!

--------------------------------------------------------------------------------

Hi Everybody, I am new to the board and registered with the name 'Auricula,' which was accepted at the time. When I try to post I am told the username has been taken. For the moment I will try to post under 'XXX.'

I am very enthusiastic about the ideas posted in this thread so far and could best help with making editorial suggestions. I was trained as a technical editor at a medical publishing company and worked in the field for over 20 years. I was diagnosed with severe obstructive sleep apnea last spring at age 65 but feel I had symptoms dating to childhood, so I am very interested in making this condition better known to the public. Had my internist recognized the signs that were there 10 years ago perhaps my condition could have been arrested at the mild or moderate stage.

Following is a cut-and-pasted version of the original draft with some suggestions based on just a quick reading. If you would like me to do a careful editing of a final draft it would be my pleasure.

The title is great and will catch the reader's attention. The quality of the writing is quite professional.

Are You Sleeping with the Enemy?

By SleepGuy

There’s much to be said about sleep apnea: It may well be the most significant, costly, easily treated, and least understood public health issue facing our nation. The most recent studies predict that over 50 million Americans (one third of all men and one fifth of all women) are at “high risk” for having sleep apnea. And very few of them have the slightest idea what sleep apnea is, much less that it may be affecting their lives in profound ways.

Apnea is the medical term for “stopping breathing.” Sleep apnea is the temporary cessation of breathing during sleep, often lasting for ten seconds or longer. At that point the body wakes up just enough to resume breathing and disrupt sleep, but usually not enough to awaken the individual. As a result, most people suffering from sleep apnea are not aware of their condition. The most common type, obstructive sleep apnea [ADD '(OSA)' SINCE YOU USE ACRONYM LATER?], occurs when the tongue and/or other soft tissues in the throat block the airway. Apneas can occur dozens or even hundreds of times every night. Common symptoms include loud snoring and a gasping or snorting sound, high levels of daytime fatigue, irritability, [ADD 'MALAISE AND'?] depression, and loss of judgment. [ADD 'IMPAIRMENT OF SHORT-TERM MEMORY'?] [ADD SOMETHING RELATING TO FAMILY OR INTERPERSONAL RELATIONSHIP PROBLEMS?] [ADD LOSS OF PRODUCTIVITY/PERFORMANCE IN THE WORKPLACE?] [DISCUSS THE REPERCUSSIONS TO THE BRAIN WHICH IS STARVED FOR OXYGEN?]

The Astounding Prevalence of Sleep Apnea in America
The numbers are shocking. The most recent studies have shown that one in four adults in the United States (31% of all men and 21% of all women over 1 [SOMEHOW THE PREVIEW SCREEN IS SHOWING A SMILEY FACE INSTEAD OF THE '' HERE] [AGAIN THERE IS A FACE INSTEAD OF AN EIGHT AND PARENTHSIS; WHY IS A MYSTERY TO ME'] is at “high risk” for OSA, based on analysis of the National Sleep Foundation’s 2005 Sleep in America survey. Another recent study showed that one third of adults who visit a primary care doctor are at “high risk” for sleep apnea. Based on the 2000 Census, that means that between 50 and 65 million Americans likely suffer from sleep apnea. This estimate far higher that previous estimates, which estimated that [SUGGESTED REVISION TO AVOID USING ESTIMATE 3X -- 'THIS IS FAR HIGHER THAN PREVIOUS ESTIMATES, WHICH PROJECTED'] between 10 and 18 million Americans had [HAVE] sleep apnea. Increasing obesity rates and an aging U.S. population have been cited for the significant increase in OSA prevalence estimates.

The Surprising Human and Economic Toll
According to the National Commission of Sleep Disorders Research, 38,000 cardiovascular deaths a year in the United States are directly attributable to sleep apnea. On top of that, sleep apnea is associated with a large number of serious, co-morbid medical and psychological conditions Sleep apnea is also related to a large number of medical and psychological conditions, such as hypertension, abnormal heart rhythm, sleep deprivation, stroke, hearth disease, diabetes, depression, memory loss, poor judgment, and change in personality. As a result, undiagnosed and untreated sleep apnea victims are significant consumers of healthcare services.

In Canada, sleep apnea victims were shown to consume 23 to 50% more medical services in the five years prior to diagnosis than control subjects, with hypertension and cardiovascular disease accounting for the majority of increased costs. A recent study from Israel also showed that healthcare utilization was 1.7-fold higher by sleep apnea patients compared to the control group, with the upper 25% of the most costly sleep apnea patients [UPPER 25% OF THE SLEEP APNEA PATIENTS WHO CONSUMED THE MOST RESOURCES] accounting for 70% of the total healthcare expenditures. Other studies have demonstrated that successful sleep apnea treatment results in significant improvement in co-morbid conditions.

In the United States, total healthcare costs associated with cardiovascular disease is [ARE] estimated to be $40.4 billion annually, [REVISION NEEDED HERE -- THE COSTS DID NOT CAUSE THE FATALITIES; PERHAPS MAKE A NEW SENTENCE AND CLARIFY THE FOLLOWING PHRASE] causing over 685,000 fatalities in 2003. Hypertension healthcare costs in the United States are approximately $19 billion. It is not known what percentage of all cardiovascular and hypertension healthcare costs are [IS] attributable to untreated sleep apnea but in light of the fact that between 50 and 65 million Americans are at high risk for the disease, it stands to reason that undiagnosed and untreated sleep apnea account for hundreds of millions—perhaps billions—of healthcare dollars spent treating conditions that could be more effectively and far more economically treated as a sleep disorder. [SOMETHING COULD BE SAID HERE ABOUT IMMENSE SAVINGS IN PHYSICAL PAIN AND MENTAL ANGUISH THAT COULD BE AVOIDED FOR PATIENTS WHO WILL NOT NEED INVASIVE HEART TESTS, PROCEDURES, AND SURGERIES, TO SAY NOTHING OF SAVINGS OF LIVES OF THOSE WHOSE DISEASE WILL NOT PROGRESS TO DIRE STAGES AND DEATH.]

Collateral Impacts
Collateral impacts arising from 50 to 65 million clinically sleep-deprived people in the United States are almost incalculable. One report focusing on highway safety impacts from sleep apnea concluded that more than 800,000 sleep-apnea related highway accidents occurred in 2000, resulting in 1,400 fatalities and costing nearly $16 billion. If the same analysis were performed today using the new, much higher sleep apnea prevalence rates, the highway safety impacts would probably be twofold higher. Sleep apnea-related losses due to worker productivity, industrial accidents, clerical mistakes, sick leave, and so forth would be almost impossible to calculate but given the numbers no doubt amount to the billions of dollars annually. On top of this, the personal quality of life impacts—depression, personality changes, lack of judgment, irritability, etc.—cannot possibly be measured in economic terms.

Simple, Economic Treatment
The best news in sleep apnea is that it is a condition that is easily and economically treated. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for obstructive sleep apnea and has been proven to be highly effective in treating sleep apnea and improving a number of co-morbid conditions. CPAP therapy consists of a ventilatory device that applies positive airway pressure at a constant, continuous pressure to help keep the airway open, allowing the patient to breathe normally during sleep.

Where to Go from Here
The biggest problem facing sleep apnea is public awareness. Unfortunately, a large number of doctors are still not very familiar with sleep apnea or its treatment. An excellent place to start is for an individual who suspects he or she may be suffering from sleep apnea to fill out a one-page, ten question survey called the “Berlin Questionnaire” that is widely available on the Internet. This questionnaire is simple, fast, and is highly predictive of sleep apnea—the positive predictive value of the survey for people scoring as “high risk” is 89%. A number of overnight screening assessment tools are also available. A formal sleep study is necessary, however, to diagnose sleep apnea and obtain CPAP treatment.

POSSIBLE ADDITIONS
Mention treatment alternatives to CPAP, e.g. dental devices and ENT surgery?
State that most insurance plans, including Medicare, will pay for testing and therapy.
Give an actual link to the Berlin Questionnaire?

[Alisha]

Outstanding job, SleepGuy. We are indebted to you for your work and it should help all readers of this board to move forward to get the word out. Now for my two cents worth.

"Increasing obesity rates and an aging U.S. population have been cited for the significant increase in OSA prevalence estimates."


I don't know who "cited" this, but IMHO, including this statement might keep more away from the sleep labs than alert them they may have sleep apnea, and it would not help educate the medical profession that OSA is wide-spread among the young and old, obese and sometimes even the slimmer population. Do we know how many are obese because of apnea ..... or how many who are finally diagnosed have, in reality, had apnea for 30 plus years?

If they had "cited" more people are 'finally being properly diagnosed for apnea' due to "Increasing obesity rates and an aging U.S. population" I would be more inclined to agree. I would think the "increase in OSA prevalence estimates" are merely because of the slow but increased awareness of OSA. Nobody knows how many of our parents, grandparents, great grandparents......have died because of strokes, etc., caused by undiagnosed OSA.

The only other thing I noticed is that napping or daytime sleepiness is not emphasized as being a major cause of lost production, accidents.....

We greatly appreciate your writing this up! This can be a great tool for all of us to send to our radio and tv stations before March 8th.

Regards,

Alisha

[SleepGuy]

Thanks for the continuing input! I'll keep revising the article.

Questions for everyone:

1. How important are actual citations for purposes of this article? On the one hand they make it authoratative. On the other hand they make it a lot longer, harder to read, and more intimidating to get through. I have opted to keep it reading more like a newspaper article.

2. Are URL references helpful? I think they would suffer from the same drawbacks but would be a great addition to an online version of the article.

[Slinky]

I would suggest keeping the source citations simple such as "the National Sleep Foundation", "the FDA", or even "1996 research by the National Commission of Sleep Disorders".

I am also of the opinion one "can' tweak too much and too long and end up w/a 30 page article not as clear and concise as your original. Take these suggestions and the article and let them set a few days and then make a last revision or two and go with it.

[drbandage]

This is really getting good!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

':D '

[SleepGuy]

Now featuring an outstanding quote from a Doctor stating that OSA is like being assaulted every night all night by your own sleep disorder . . . .that if someone tried to smother you with a pillow all night you'd call the police!

just perfect!