Inside Sleep
Diversity and Sleep Apnea
- By Barbara Phillips
- May 01, 2010
We all know the stereotypical sleep apnea patient: a middle-aged, sleepy, overweight
man. Clinicians of all stripes are well aware that such patients will very likely
benefit from CPAP therapy, particularly if they have hypertension or sleepiness.
But it’s time to expand the clinical recognition of sleep apnea beyond
this classic presentation. Many individuals who have sleep apnea and would likely
benefit from treatment are going undiagnosed and untreated because they don’t
“look like” they should have sleep apnea. We can do better.
Let’s start with older women. The prevalence of obstructive sleep apnea
skyrockets for postmenopausal women after about the age of 50, whether or not
they are overweight or obese. Women with sleep apnea don’t present the
same way that their male counterparts do. They are more likely to complain of
insomnia, depression and nightmares, and less likely to have been observed to
stop breathing during sleep. Their sleepdisordered breathing is more likely
to be subtle (Upper Airway Resistance Syndrome) and to occur primarily in rapid
eye movement (REM) sleep. This makes it important to perform careful studies
in order not to overlook the disease in this group. Untreated sleep apnea may
be contributing to their symptoms.
In addition, certain ethnic groups, including particularly Asians and African
Americans, are at increased risk for sleep apnea. The prevalence of obstructive
sleep apnea in several Asian countries has been documented to be comparable
with rates in the United States, even though the incidence of obesity in Asia
is still relatively uncommon. So the thin Asian individual who has snoring,
sleep complaints and premature cardiovascular disease, for example, is quite
likely to have sleep apnea. This also appears to be true for African Americans.
Cardiologists have begun to recognize the strong association between two particular
cardiac diseases and sleep apnea. Congestive heart failure (CHF) is frequently
associated with both obstructive and central sleep apnea. Treatment with CPAP,
if effective in eliminating the apneas (which it isn’t always, for those
with central apnea), can improve cardiac function in patients with CHF. In addition,
untreated sleep apnea is associated with cardiac arrhythmias, especially atrial
fibrillation. Up to half of those with atrial fibrillation are documented to
have sleep apnea, if tested. Most of these individuals are neither sleepy nor
overweight, so the likelihood of obstructive sleep apnea may not be considered.
People with what otolaryngologists call “mandibular insufficiency”
are also at increased risk for significant obstructive sleep-disordered breathing.
A receding chin (retrognathia) or a small lower jaw results in a tongue that
is likely to be pushed back into the airway, resulting in restricted or totally
obstructed inspiratory airfl ow, particularly when the person lies on his back
and/or is in REM sleep.
Does it matter if we continue to overlook these patients with atypical presentations?
You bet. We know that untreated sleep apnea is associated with hypertension,
car accidents, poorer diabetic control and reduced cognition, not to mention
the variety of adverse cardiovascular conditions, including stroke. Treatment
can make a difference for these people — and for those in the car or on
the road with them!
It’s time for the medical community to reach beyond the low-hanging
fruit of the corpulent middle-aged man and expand our diagnostic and therapeutic
reach to people who don’t meet the classic textbook presentation, but
do suffer the classic complications of obstructive sleep apnea.
So as physicians come to recognize the wider incidence of sleep apnea in these
different demographic groups, you as providers of home medical equipment will
find that your patient population grows more diverse in gender and ethnicity.
And that will be a good indicator the medical community is embracing its responsibility
to treat sleep disorders as the serious health threat that they are.
This article originally appeared in the Respiratory & Sleep Management May 2010 issue of HME Business.
About the Author
Barbara Phillips, MD, MSPH, is currently a professor of pulmonary, critical care and sleep medicine in the Department of Internal Medicine at the University of Kentucky College of Medicine. Phillips is board certified in internal medicine, pulmonary medicine and sleep medicine. She directs the Sleep Center at the University of Kentucky Good Samaritan Hospital in Lexington. Additionally, Phillips serves on the Board of Regents of the American College of Chest Physicians, as a consultant to the National Board of Respiratory Care and as chair of the Steering Committee of the Sleep Institute of the ACCP. She is a past chair of the National Sleep Foundation and has served on the boards of the American Lung Association, the American Academy of Sleep Medicine, the Medical Advisory Board of the Federal Motor Carrier Safety Administration and the American Board of Sleep Medicine. She has received a Sleep Academic Award from the National Institutes of Health.