A Good Night’s Sleep Can Be a Matter of Life and Death

Over the past three years, I have been writing the Wake Up! You’re Snoring blog with two main objectives: first, to educate you, the public, about sleep disorders, and second, to provide compelling reasons—preferably scientific evidence—why a person who may have a sleep disorder should get diagnosed and, if necessary, properly treated.

There is no shortage of scientific studies being released on a regular basis showing links between obstructive sleep apnea (OSA), insomnia, and other sleep disorders, and myriad negative health conditions, from daytime sleepiness to increased depression.

I wasn’t surprised to see a new study showing a link between insomnia, the loss of hope, and an increased risk of suicide. In a study led by Dr. W. Vaughn McCall, chair of the Medical College of Georgia at Georgia Regents University, researchers studied the mental state of 50 depressed patients between the ages of 20 and 80. More than half of the patients had attempted suicide, and most were taking an antidepressant.

It is established that insomnia and nightmares often go hand-in-hand, and are both known risk factors for suicide. The new study reaffirms that link, but researchers also wanted to find out what effect feelings of hopelessness about sleep had on suicide risk.

In the study, the researchers specifically focused on the relationship between insomnia and suicide risk by asking questions about dysfunctional beliefs about sleep, such as, “Do you think you will ever sleep again?” The scientists used psychometric testing to objectively measure the mental states and personalities of the 50 depressed patients.

Dr. McCall published the results of the study in the Journal of Clinical Sleep Medicine, the journal of the American Academy of Sleep Medicine. In the report, Dr. McCall stated, “It turns out insomnia can lead to a very specific type of hopelessness, and hopelessness by itself is a powerful predictor of suicide.” Dr. McCall also said, “The likelihood of being suicidal at least doubles when insomnia is a symptom.”

McCall and his colleagues have, in effect, discovered a new predictor for suicidal thinking. But why the link between lack of sleep and suicidal thoughts? Dr. McCall explained that, “It turns out insomnia can lead to a very specific type of hopelessness, and hopelessness by itself is a powerful predictor of suicide.” He continued, “If you talk with depressed people, they really feel like they have failed at so many things. It goes something like, ‘My marriage is a mess, I hate my job, I can’t communicate with my kids, I can’t even sleep.’ There is a sense of failure and hopelessness that now runs from top to bottom, and (insomnia) is one more thing. It was this dysfunctional thinking — all these negative thoughts about sleep — that was the mediating factor that explained why insomnia was linked to suicide,” said McCall.

The significance of this study, like many others, is that it not only educates people about the risks associated with insomnia and other sleep disorders, but it challenges the medical community to look at things a little differently when diagnosing and treating.

In this case, examine lack of sleep and insomnia when treating depression and suicidal thinking.  The finding also is a reminder to physicians that depressed patients who report increased sleep problems should be asked if they are having suicidal thoughts, McCall said.

If you’re having trouble sleeping, here are some tips to increase your chances of getting a good night’s sleep.

• Use the bedroom for sleep. With so many electronic distractions in our lives, it’s important to re-claim your bedroom for its intended purpose: rest and sleep. Move the TV and computer out of the bedroom, or at the very least, do not watch TV, work on the computer or check your blackberry close to bedtime.
• Stick to a bedtime routine. Try to go to sleep before 10:00 pm at night, and wake up around the same time every day, even on weekends. Try to keep to within 20 minutes of the same time each morning and night.
• Do activities that will get you ready for bed. Before bed, do activities that will promote sleepiness, such as a taking a warm bath, or reading a book or magazine.
• Maintain a cool temperature in your bedroom. A cool but comfortable temperature is ideal for sleep. Too warm and you will be fitful, too cold however can be uncomfortable and disturb your sleep.
• Exercise regularly but not after the late afternoon. Even though exercise helps regulate sleep, rigorous exercise causes endorphins in the body to circulate which can have a stimulant effect, and keep you awake longer at night.
• Stay away from caffeine at night. The effects of caffeine are different from person to person, and may last hours after your last cup of coffee, so make your last cup of coffee, regular tea or soda earlier in the day.
• Avoid alcohol and medicines that make you drowsy. Even if you think it is helping you fall asleep initially, alcohol and medicines that makes you drowsy may affect your sleep throughout the night.

Remember, people need an average of 7-8 hours of restful sleep to fully take advantage of its restorative power and avoid daytime symptoms of fatigue. If a regular, peaceful routine incorporating the tips above doesn’t help you start sleeping peacefully throughout the night, contact your doctor. You may have a more serious cause of sleeplessness such as snoring, sleep apnea or chronic insomnia. Getting treated could prevent heart disease, hypertension and stroke.

Snoring a Top Predictor of Heart Attacks and Strokes

By Dr. David O. Volpi

I read a study recently that I immediately knew I had to make you aware of.

Researchers at Henry Ford Hospital in Detroit found that snoring is a bigger risk factor for heart disease, including stroke and heart attacks, than being overweight, having high cholesterol, and even smoking! Yes, you read that right—snoring is an even bigger risk factor for heart disease.

The study, which was submitted to The Laryngoscope journal, is the first of its kind to show a link between snoring and heart disease, similar to other risk factors, such as sleep apnea, obesity, smoking and high cholesterol are also linked to heart disease.

Snorers showed arterial damage

For the study, Dr. Robert Deeb, MD, and senior study author Karen Yaremchuk, MD, reviewed the data of 913 patients, all between the ages of 18 and 40, who had been evaluated by the Henry Ford sleep center between December 2006 and January 2012.

The researchers noticed that the carotid arteries—the arteries that supply oxygen-rich blood to the brain—had thickened among the snorers, indicating that arterial damage had occurred due to snoring.

The researchers hypothesized that the thickening of the artery walls could have been due to the trauma and inflammation caused by snoring. But previous research on sleep apnea and artery disease has found the opposite: arterial damage comes first, reducing the oxygen level in the blood, leading to interruptions in breathing. The thickening of the arteries may also be contributing to the snoring in the patients.

Even more interesting: The snorers’ arterial walls had thickened, even though none of the patients had been diagnosed with obstructive sleep apnea (OSA). While OSA often develops from snoring and has been known as an indicator of cardiovascular disease, there’s been little evidence until now to prove that arterial damage can actually begin with snoring.

What these results mean

So what are the medical implications of the Henry Ford study? Let’s review coronary artery disease for a moment. Coronary artery disease (CAD), also known as atherosclerosis, occurs when waxy plaque builds up on the inner walls of the arteries.

Over time, the arterial walls thicken and stiffen, restricting blood flow to the heart and/or brain. It is commonly know that CAD is a precursor to conditions such as heart attack, stroke, and heart failure.

The results of the Henry Ford study—that the carotid arteries had thickened among the snorers, is important to pay attention to because it means that snoring, not just OSA, is a high risk factor for coronary artery disease, heart disease, and other related conditions.

Drs. Deeb and Yaremchuk’s research is groundbreaking because arterial blockage and other forms of heart disease are usually detected only after significant permanent damage has been done.

This new research should encourage snorers—and those who love them—to visit a doctor to discuss cardiovascular health and stroke prevention, and get properly diagnosed and treated.

The research is clear that doctors should add snoring to the list of coronary artery disease risk factors, along with high blood pressure, high cholesterol, diabetes, smoking and family history. Perhaps if patients and their doctors considered snoring a serious health threat and treated it accordingly, there would be a great reduction in heart disease.

Veterans with Sleep Apnea: A Growing Human Issue

Whether or not you personally know someone who has served in Iraq, Afghanistan or someplace else on foreign soil, our returning veterans deserve our help and attention. While many have the scars of physical injury, many more veterans bear silent scars. A little known fact but of increasing concern in the medical community is that a growing number of veterans are suffering from obstructive sleep apnea (OSA), and its symptoms can be devastating for our returning war heroes as they readjust to civilian life

Consider these statistics: According to the U.S. Department of Veterans Affairs (VA), one out of every five war veterans has been diagnosed with OSA — compared with only five out of 100 civilians in the general population. And between 2008 and 2010, the number of veterans who received medical benefits related to sleep apnea grew by 61 percent, from 39,145 cases in 2008 to 63,118 cases in 2010.

These numbers beg the question: Why do war veterans suffer from sleep apnea more than non-war veterans and civilians? Some VA doctors believe that it is due to the high number of repeat deployments to Iraq and Afghanistan — soldiers are being exposed to higher levels of dust, smoke, stress and violence.

But what is at the core of this connection between war, OSA and other related conditions, such as daytime sleepiness, memory loss, a decrease in work productivity, obesity, heart disease, diabetes, and hypertension. Researchers at the Wayne State University (WSU) School of Medicine are beginning to find out.

Since the mid-2000s, WSU researchers have been studying 145 American immigrants who left Iraq before the 1991 Gulf War, and 205 who fled Iraq after the Gulf War began. All lived in the Detroit area at the time, and were asked about socio-demographics, pre-migration trauma, how they rated their current health, physician-diagnosed and physician-treated OSA, and any somatic and psychosomatic disorders.

The study’s lead investigator, Bengt Arnetz, M.D., Ph.D., M.P.H., School of Medicine professor of occupational and environmental health, and deputy director of the Institute of Environmental Health Sciences at Wayne State said, “It may be the stress of war that leads to fractured sleep, and that no one had explored this possible link before, although basic research suggests it as plausible.”

The results of the study are published in the October 2012 issue of Psychosomatic Medicine in the article, "Obstructive Sleep Apnea, Post-traumatic Stress Disorder, and Health in Immigrants.” The research showed that those who left Iraq after the war began and suffered from mental disorders such as post-traumatic stress disorder (PTSD) and depression, and self-rated their physical health as worse than their actual health, were 43 times more likely than pre-Gulf War immigrants to report OSA and later develop major chronic health issues, such as cardiovascular disease.

On the results, Arnetz said, “It's a known fact that the more exposure to violence you have, the more likely you are to report post-traumatic stress disorder (PTSD) and depression, and the worse your self-rated health is, the more likely your actual health will suffer in five to 10 years.” And I reiterate, those who were exposed to the violence of the war in Iraq were almost twice as likely to experience PTSD and depression, but also Obstructive Sleep Apnea and other chronic health conditions. I applaud Arnetz and his colleagues’ efforts, and encourage them to continue their studies so that we in the medical community can better understand, diagnose and treat war- and stress-related health conditions.

What about treatment? Diagnosing OSA in veterans can be trickier than non-veterans because of the possibility of other military-related medical conditions, such as PTSD. In addition, some military veterans suffering from OSA may underestimate the health benefits of restorative sleep, rather than be properly diagnosed and treated since its common during deployment to have fractured sleep patterns.

The good news is that there is more awareness of OSA than ever before, especially within the military. Back in February 2012, Ventus Medical, the company that makes Provent Therapy, announced that the U.S. Department of Veterans Affairs approved a multi-year, Federal Supply Schedule contract that would enable more veterans to get Provent Therapy treatment — a small, non-invasive nasal device for the treatment of obstructive sleep apnea (OSA).

This is good timing, considering that a substantial percentage of veterans don't accept or adhere to continuous positive airway pressure (CPAP) therapy, even though it is a safe and effective treatment. According to Richard B. Berry, M.D., Professor of Medicine at University of Florida, "There is a great need for access to new, clinically-proven therapies—particularly easy-to-use treatments — for the increasing number of veterans with obstructive sleep apnea."

As more and more Iraq and Afghanistan veterans are realizing their post-war health problems, and because many Vietnam veterans are getting older, the number of veterans applying for OSA-related disability benefits will only continue to rise in the coming years. While OSA is a chronic condition creating a significant burden on the Veterans Healthcare System — the VA spends upwards of $500 million a year to treat veterans with sleep apnea — I believe that it is our duty as a nation to provide proper OSA treatment to our veterans to prevent additional chronic health issues. To read more about the study, go to the Wayne State University website.

Less Than Six Hours Sleep/Night Increases Strokes

Lack of sleep and an increase in strokes. According to new research, the two conditions are very connected, even in otherwise healthy adults.

In early June, the University of Alabama at Birmingham released the results of a study that regularly sleeping less than six hours a night significantly increases the risk of stroke symptoms in middle-age to older adults who are of normal weight and at low risk for obstructive sleep apnea (OSA). That’s worth repeating: Less than six hours of sleep per night increases the risk of strokes in adults of normal weight and not at risk for OSA.

It seems that under six hours of sleep per night is the critical variable, but why? Let’s take a look at the study. The University of Alabama researchersfollowed 5,666 people  for up to three years who had no history of strokes or stroke-like symptoms, transient ischemic attacks (when blood flow to the brain stops for a brief period causing stroke-like symptoms), or high risk for OSA at the start of the study.

For a period of three years, the researchers followed and studied the subjects’ first stroke symptoms, stroke risk factors, depression symptoms, demographic information and other various health behaviors. What they found was—after adjusting for body-mass index (BMI)—there was a strong association between daily sleep periods of less than six hours and a greater incidence of stroke symptoms for middle-age to older adults, even beyond other risk factors. Interestingly, the researchers did not find any link between short sleep periods and stroke symptoms in overweight and obese participants.

Still, the connection between short sleep and strokes is worthy of great attention from the medical community and general public. I agree with the Alabama study’s lead author, Megan Ruiter, PhD., who said, “The results of the Alabama study provide a strong argument for increasing physician and public awareness of the impact of sleep as a risk factor for stroke symptoms, especially among persons who appear to have few or no traditional risk factors for stroke.”

It looks like the medical community is taking this message to heart. Another study announced in late July is going on at the Alberta Health Services and the University of Calgary.  There, Dr. Patrick Hanly of the university’s Hotchkiss Brain Institute is leading a study to learn more about the physiological connection between sleep apnea and stroke—specifically, the brain’s blood flow response in people with and without sleep apnea.

For the study, participants with sleep apnea stay overnight in the sleep laboratory at Calgary’s Foothills Medical Centre, where their breathing and cardiovascular responses are continuously monitored while they sleep. The next day, their brain blood flow response to reduced oxygen levels is assessed while they are awake. Then, the participants receive supplemental oxygen during sleep for two weeks, and are tested again to see if their cerebral defense mechanisms have improved. The researchers are also studying people without sleep apnea to see if their cerebral defense mechanisms function better than in those with sleep apnea. Hanly and team’s theory is that it is the lack of oxygen, or hypoxia, that people with sleep apnea experience during sleep that impairs the body’s normal defense mechanisms in the brain. A better understanding of this connection will lead to better prevention and treatment strategies.

I applaud the work of the Alabama and Calgary researchers. It’s time we all wake up to the health benefits of more–and better—sleep.

For more information, read the University of Alabama at Birmingham study, “Under 6 Hours of Sleep Tops Risks for Stroke in a Low-risk Population.”

Women and Sleep Apnea: At Greater Risk Than We Thought

A few months ago, my blog entitled, “Who’s Suffering More from Lack of Sleep — Men or Women?”  discussed “the sleep battle of the sexes,” specifically, who suffers more from sleep disorders — men or women? In that blog, I made the point that, while men are generally more likely to suffer from obstructive sleep apnea (OSA) than women, men are also more likely to get tested and treated for the disorder.

That’s not good, because we are learning that many more women than previously thought suffer from OSA, and leaving it unchecked can have dire consequences on a woman’s cardiovascular health.

I read a recent women and sleep apnea study out of Spain that said that women with untreated severe OSA are three and a half times more likely to die from cardiovascular disease than women without OSA. Three and a half times!

Thankfully, the study also showed that women who treat their severe sleep apnea at night with a technique called continuous positive airway pressure (CPAP) significantly reduce their risk of heart attack-related deaths to about the same risk level as women without OSA.

The study was conducted by Dr. Francisco Campos-Rodriguez, director of the sleep-disordered breathing unit at Valme University Hospital in Seville, Spain. To read a summary of the study, go to the Annals of Internal Medicine.

The research is a wake-up call to both patients and doctors because it is the first published results that link OSA to cardiovascular death in women, and that CPAP treatment can reduce OSA-related mortality risk.

It also shines a light on the need for more research regarding sleep apnea and women, as well as the need for women to take their symptoms seriously, and not just consider OSA “a man’s disease.”

What Women Should Know About Sleep Apnea

So how do you know you may have obstructive sleep apnea? Some common symptoms include snoring, paused breathing during sleep and excessive sleepiness during the day. Increased blood pressure is another sign you may have sleep apnea.

While sleep apnea is more common in men, OSA increases in women after age 50. According to the National Sleep Foundation, one in four women over age 65 have sleep apnea.

Being overweight also increases a woman’s risk of having sleep apnea. Menopausal women are three and a half times more likely to get OSA, possible due to reduced amounts of progesterone.

If you have any of the symptoms mentioned above, and suspect that you may have sleep apnea, please get checked out by a doctor who specializes in sleep disorders. Be specific about the symptoms you are experiencing. Many times, sleep apnea can be misdiagnosed in women as chronic fatigue, insomnia, depression, or some other non-specific condition.

Also, some doctors still associate sleep apnea more with men than women, and are too quick to prescribe a medication, rather than do a full sleep disorder work up. Again, to try and avoid misdiagnosis, go to a qualified sleep specialist and be specific about your symptoms. Don’t wait — it could save your life.

Stop Snoring — It Can Be the Secret to Happy Marriage

I am by no means a marriage therapist. However, I hear couples complain all the time in my practice. They come in for a snoring test appointment, and within seconds the husband makes a comment such as “my wife made me come.” Snoring is more common in men than women, but the reverse is also common.

The snoring spouse who feels “dragged” to the doctor’s office is resentful that his or her snoring problem can’t be left alone. The spouse that does the dragging-in is frustrated and tired. Ordinarily affectionate couples can have a strain in their relationship caused by snoring. Sometimes if it wasn’t for their spouse, a snorer wouldn’t even know they had a problem. As one of my patients recently told me, “I was very surprised when my lovely wife first clued me in that I was snoring at night. It was disturbing her sleep, but I didn’t realize that snoring was the cause of my own fatigue.”

The reason for resentment is understandable. Snoring can cause daytime symptoms that can cause serious problems in one’s waking life, and unfortunately, it is not just the snorer that suffers – the snorer’s spouse can suffer just as much. According to the National Sleep Foundation,  39% of American adults get less than seven hours of sleep each weeknight, and more than one in three (37%) are so sleepy during the day that it interferes with daily activities. The sleep loss associated with snoring—whether it’s the snorer or the bed partner who is awakened by the snoring, interrupts important recuperative sleep which can impair a person’s ability to perform cognitive tasks involving memory, learning, reasoning, and mathematical processes. It can impair motor skills and can cause morning headaches, irritability, burnout and depression to mention just a few symptoms.

Symptoms can be even more severe for the snorer if they have sleep apnea, a condition which causes them to stop breathing often many times a night, and wake gasping for air. Sleep apnea is linked to lung and heart disease, diabetes, obesity and stroke.

The disruption of sleep from snoring is causing couples to have a hard time sleeping together. Fifty-three percent of adults say they have relationship problems because of their or their partner's sleep disorder, the National Sleep Foundation found in a recent study. To avoid the symptoms of daytime sleepiness, many couples choose not to sleep together in the same bed.

In the book, "Two in a Bed: The Social System of Couple Bed Sharing," author Paul C. Rosenblatt interviewed 42 couples, and examined how sharing a bed affects the couple’s relationship. Many couples described the intimacy and comfort level of sleeping in the same bed is extremely important to their relationship. As he describes in the book, in their time together before drifting off to sleep, “couples catch up on what's going on with one another, plan, make decisions, deal with disagreements and solve problems.”

With their hectic schedules, many couples often only have this time to catch up. It is no wonder why it’s crucial to their relationship. Unfortunately snoring can force one spouse into another room for the sake of sleep, and this crucial together time is hard to replace in their busy lives otherwise.

If your marriage is suffering because you or your spouse snores, the key to reconciling is to understand that snoring is a symptom of a physical condition, such as sleep apnea, sinusitis, or nasal obstruction and it can be treated. There are many non-surgical, in-office and minimally invasive treatments available to snorers today. Although I would never make the claim that I’ve saved marriages, I’ve heard back many times from patients who tell me that it wasn’t until after their snoring was cured did they realize how much happier they are snuggling next to their spouse again.

Irene’s Lessons

Hurricane Irene

In the days preceding Hurricane Irene, many East-coasters, myself included, experienced some sleepless nights. Preparing for the worst, it was hard to get the thoughts out of my head as I ran through the checklists of tasks to secure the house, and provisions to buy for the days we expected to be out of power.

Thankfully no one I know had any major damage to their homes. In fact, it seemed that almost immediately after the winds died down, there was an upside to the calm after the storm. As our workplace got back to normal, a business acquaintance of mine was still without power. She told me an interesting anecdote of her experience after the hurricane. She has realized, even though power hasn’t been restored yet in her home, there was a  benefit to the storm after all—she’s feeling more rested than she has in years.

She was surprised by this considering the anxiety and frustration she’s been going through learning to live with no electricity. However with a few questions about her normal sleep routine, I realized she had gotten into some bad habits and they had been getting progressively worse. For example, her bedroom contains her computer and television. She had been in the habit of before bedtime getting on the computer, checking email and instant messaging or surfing. This was causing her to go to bed later and later. With the need to conserve her cell phone battery, she put that down as well. Without the electronics to distract her for hours, she began going to bed at a decent hour. The result has been a bedtime of a reasonable hour, as opposed to her average time of 3 a.m.

When I asked if she usually fell asleep with the TV on, she admitted she felt she couldn’t go to bed without it. This is one of the worst habits one can have since not only does the TV interrupt deep REM sleep with noise throughout the night, but it is now understood from recent research that the light from the screen can interfere in the production of the hormone, melatonin, which is the natural sleep aid the body creates to tell us it’s time to go to sleep. As a result of the dark and quiet, she’s receiving a deeper, more regenerative sleep.

The dryer, cooler nights we’ve been experiencing in the New York area has also aided her in sleeping more deeply. Falling asleep in a dark, quiet, and cool room is ideal for the most regenerative sleep possible. Over the past few days, she has reset her internal sleep clock. Falling asleep when she feels sleepy and sleeping deeply throughout the night has allowed her to wake up on her own without the aid of an alarm clock, feeling rested and alert throughout the day—the very definition of restorative sleep. Learning the how good she feels after just a few night’s rest, she’s determined not to fall back on bad habits.

She cites some other important benefits as well. For example, the neighborhood children are playing together outside instead of through their gaming headsets. Irene has given her hours of one-on-one time with her son. Instead of computer, TV and video games, they’ve played board games and talked. Her son was set to start high school this week, and since that is delayed, she feels she’s been grateful for a few more summer days together before the hustle of the school year begins.  

Unobstructed by light pollution, the other night they watched the clear night sky together, and talked about constellations they could never see before. Many of us on in the tri-state region were very lucky that we had no damage. Some lost everything. Some of us simply lost power for a few days. As frustrating as that can be, as some still wait for the lights to come back on, maybe we can thank Irene for some gifts.

Loud Snoring Predicts Metabolic Syndrome

Add “metabolic syndrome” to the growing list of health risks and symptoms caused by or linked to snoring. In a study just released in the December issue of the journal SLEEP, it was found that adults were two times more likely to develop metabolic syndrome if they snored loudly during sleep.

Metabolic syndrome is a group of combined risk factors that indicate a person may have an increased chance of developing coronary artery disease, stroke, and type 2 diabetes. The syndrome is becoming common in the United States and is related to obesity. Two of the most common risk factors associated with the syndrome are extra weight around the middle of the body (central obesity), and insulin resistance, in which the body cannot use insulin effectively.

Led by researcher, Wendy Troxel of the University of Philadelphia, the study followed 812 adults (ages 47-74; 36% African American; 67% female) in an "ongoing, community-based prospective." This was the first prospective study to link metabolic syndrome with snoring, as well as with the sleep disorders difficulty falling asleep (DFA), unrefreshing sleep and insomnia. Those studied were free of metabolic syndrome at the start, had completed a baseline sleep questionnaire, and participated in a metabolic syndrome evaluation three years after the baseline. A subset of 290 participants were measured for their apnea-hypopnea index (AHI) using a portable monitor.

The study examined the risk of developing factors of metabolic syndrome according to participant’s individual snoring and sleep symptoms and insomnia. Sleep complaints have been highly prevalent with cardiovascular disease (CVD), and interestingly, 14 percent of the participants developed metabolic syndrome while they were participating in the study.

The results of the study indicated that those who snored loudly were twice as likely to develop metabolic syndrome, and also predicted specific metabolic abnormalities such as hyperglycemia and low high-density lipoprotein cholesterol. Even when adjusted for AHI or the number of metabolic abnormalities at baseline, loud snoring remained a significant predictor of metabolic syndrome, whereas difficulty falling asleep, unrefreshing sleep and insomnia had less significance. It is believed that evaluating sleep symptoms will help physicians identify patients at risk for developing metabolic syndrome.

To read more about the research results, visit SLEEP.