Sleep Apnea: “Why am I so Tired?”

Sleep apnea, interrupted breathing while sleeping, has been linked to hypertension, heart disease, elevated blood sugar and stroke. There are a variety of diagnostic and treatment options available to treat sleep apnea and help sufferers regain a good night’s sleep. Penn is pioneering one of the latest options, which uses minimally invasive robotic surgery to treat sleep apnea patients who have problems with excess tissue at the base of the tongue.

Sleep apnea tends to be more common in men, and the bed partner often has sleep issues because of the snoring or gasping. In fact, it is often the wife who nudges her husband to seek treatment for this disorder, according to Ronald Barnett, MD, pulmonologist and sleep medicine specialist at Penn Medicine Valley Forge.

Grace Pien, MD, a specialist in women’s sleep issues, says a woman’s risk of developing sleep apnea increases after menopause. Dr. Pien is currently studying the role of estrogen and other reproductive hormones in protecting women from sleep apnea.

“Women appear to be protected from sleep apnea during their child-bearing years, but the risk increases once they enter perimenopause, and the risk for post-menopausal women is three times greater compared to premenopausal women,” said Dr. Pien.

A thorough sleep evaluation reviews all aspects of a person’s sleep habits, physical characteristics and associated medical conditions to help physicians make a diagnosis of sleep apnea. Usually, patients undergo an overnight sleep study, which can be performed in a sleep laboratory, or increasingly, in patients’ homes using home sleep monitors. About 80 percent of people tested are diagnosed with sleep apnea, according to Dr. Barnett.

Sleep studies are often recommended for patients who are overweight and have a history of hypertension and cardiac arrhythmias because of the link between sleep apnea and heart disease, according to Theodhor Diamanti, MD, Penn cardiologist. “Sleep apnea causes the oxygen levels to drop and low oxygen levels can lead to life-threatening cardiac arrhythmias,” said Dr. Diamanti.

Patients treated for sleep apnea are better rested, have higher oxygen levels, and are more active and able to live healthier lives.

The most common, and most successful treatment for sleep apnea is CPAP — continuous positive airway pressure. The positive airflow blows into the nose and/or mouth and keeps the airway open so that breathing is not interrupted. The treatment works for about 90 percent of patients.

Continuous positive airway pressure (CPAP) helps many patients who suffer from sleep apnea. But for those patients who can’t tolerate CPAP, surgery – including minimally invasive robotic surgery — may help break the sleep apnea cycle.

The muscles that hold the airway open relax during sleep. When the loose tissue vibrates, someone snores. If the tissue in the back of the throat collapses, it blocks the airway and results in sleep apnea. Uvulopalatopharyngoplasty is the most common procedure for removing the excess tissue in the throat.

“In surgical management of sleep apnea we can remove the tonsils and trim the uvula and palate,” said Erica Thaler, MD, Penn otorhinolaryngologist. “Now with the introduction of transoral robotic surgery (TORS) we can also help patients who have issues with the tissue at the base of the tongue.”

Dr. Thaler said about 20 patients have been treated for sleep apnea using TORS with good results. “This is a new procedure so we are continuing to follow these patients through sleep studies,” Dr. Thaler said, “but so far our outcomes have been positive.”

To learn more about transoral robotic surgery (TORS), visit the Department of Otorhinolaryngology-Head and Neck Surgery. To schedule an appointment, please call 800-789-PENN (7366).

Brief Behavioral Therapy for Insomnia in Older Adults

Insomnia is a common complaint in the general population and among patients treated by primary care physicians.  This is particularly true for older adults who experience physiological changes in sleep with aging.  Clinicians commonly prescribe hypnotics for insomnia and the use of these types of drugs is increasing in the United States and elsewhere.  Behavioral and psychological interventions may be overlooked or bypassed in the sequencing of interventions for complaints of insomnia.

 I had previously posted on the promise of cognitive behavioral therapy for insomnia.  This therapy appears to be effective across a variety of patient groups including those with an underlying psychiatric diagnosis.  Now, a recent study in elderly subjects finds support for an even briefer intervention for those with primary insomnia.

Buysse and colleagues from the University of Pittsburgh and the Cleveland Clinic have recently published a randomized control trial of brief behavioral therapy intervention (BBTI) for primary insomnia in a group of adults averaging 71-72 years of age.  The brief intervention included direct contact with a single masters level nurse practitioner for an initial 45 to 60 minute session followed by a 20 minute direct contact session in 2 weeks.  Two 20-minute phone sessions were scheduled at one and three weeks following the initial contact session.  The authors note the sessions focused on customizing for each subject the four key elements of sleep education and stimulus control:

1. reduce the total amount of time in bed
2. get up at the same time daily regardless of sleep duration
3. do not go to bed unless feeling sleepy
4. do not stay in bed unless asleep

The control group was provided educational material that included information related to behavioral treatment of insomnia but did not include personalized contact session with the nurse practitioner.  Outcome was measured by whether subjects continued to meet criteria for insomnia as well as other secondary measures.

The BBTI group demonstrated a 67% response rate compared to only 25% response in the control group.  Remission of an insomnia diagnosis was noted in 55% of the BBTI group compared to only 13% of the control.  Most psychometric, sleep diary and actigraphy measures improved more in the BBTI group more than the control group.  Interestingly, there were no differences between the groups in polysomnography sleep lab measures including sleep latency, total sleep time and sleep efficiency.

The authors note attractive features of BBTI including:

• it is easily taught to nurse practitioners and other clinicians
• it includes a workbook that allows patients to follow exercises aimed at reducing insomnia
• the strict behavioral approach limits some of the stigma associated with psychological treatment approaches in primary care

This study supports a stepped care approach for older adults with primary insomnia.  Following careful assessment to rule out another sleep disorder, i.e. sleep apnea or an untreated psychiatric disorder, i.e. depression or anxiety disorder, a trial of brief behavioral therapy may be a good first step.  Patients who fail to respond to this step may be candidates for consideration of hypnotic or other pharmacological interventions.

Photo of Lilly Pad Flower Bloom from Maui Courtesy of Yates Photography

Buysse, D., Germain, A., Moul, D., Franzen, P., Brar, L., Fletcher, M., Begley, A., Houck, P., Mazumdar, S., Reynolds, C., & Monk, T. (2011). Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults Archives of Internal Medicine, 171 (10), 887-895 DOI: 10.1001/archinternmed.2010.535