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Health Watch: Sleep Clinics

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From the October 2013 issue of Columbus CEO

Americans are busy—busy with their jobs, their families, their many electronic devices—and one of the first and most certain casualties of this busyness is sleep. Life choices often lead to poor diet and less exercise, which further compound the problem.

According to a study by the Centers for Disease Control and Prevention, 35 percent of Americans are sleep-deprived—a condition that is linked to decreased job performance, fatal car accidents and a slew of long-term health problems.

The medical community is addressing this growing epidemic by making it easier for people to have sleep problems diagnosed and treated.

Sleep Issues

There are a number of sleep disorders, but the most common by far is obstructive sleep apnea. While some thin people suffer from the condition, it is often a result of weight gain. The soft tissues inside the throat may become enlarged so that when a person relaxes during sleep, airflow is blocked. The sleeper is repeatedly awakened, curtailing the amount of healthful, deep sleep he or she gets.

“You’re trying to breathe, but the doorway is closed off,” explains Dr. David Ralston, medical director of Mount Carmel Health System’s sleep center. Your brain knows the dangers of air deprivation. “It will keep you in the shallow waters of sleep,” he says. Ralston says apnea affects 2 percent to 4 percent of all men and 2 percent of women.

Dr. Meena Khan, an assistant professor with the Ohio State University Sleep Disorders Center, says those numbers even out once women reach menopause, which may account in part for the fact that older Americans have the highest levels of daytime sleepiness. According to the CDC study, 44.5 percent of people age 65 and older reported falling asleep unintentionally within the past month. Khan says smoking can increase the risk of obstructive apnea, and alcohol, while not a primary cause, can exacerbate the condition.

Another commonly diagnosed condition is restless leg syndrome, which manifests as a hard-to-describe discomfort that occurs around bedtime. It may be caused by iron deficiency and is frequently found among people who are pregnant or suffer from diabetes or kidney disease. It is sometimes inherited but often has little or no explanation.

“Then there’s also the vague complaint of insomnia,” says Dr. Jim Fulop, corporate medical director of OhioHealth Sleep Services. “People say they can’t fall asleep or can’t stay asleep, or a mixture of the two. It leaves them frustrated and tired during the day.”

Insomnia can be a temporary condition brought on by stress that may resolve itself. Some people develop a more chronic form of insomnia, for which it’s wise to seek professional advice.

Another ailment, central sleep apnea, is less common and occurs when the sleeper temporarily stops breathing—but not because of an obstruction.

Dr. Rami Khayat, director of the Sleep Heart Program at the Ohio State University Wexner Medical Center, is part of a team conducting an international trial of a device to treat central sleep apnea. “The condition is most commonly found in patients with heart failure and heart disease,” he says. “An implantable nerve stimulator stimulates the diaphragm. It paces the diaphragm and prevents central apnea.”

More than a third of Americans report sleep problems of some sort, but it often takes patients a while to seek help.

“The biggest issue we hear is that the patient doesn’t have a problem, but their spouse is making them come in,” Ralston says. “People think they feel fine, but once you start asking direct questions, you see perfectly clearly that everything is not fine.”

According to the National Sleep Foundation, 70 million Americans have a sleep problem of some sort, and 40 million adults suffer from a chronic sleep disorder. Curiously, 77 percent of adults say their bed partner may have a sleep disorder.

“If other people notice, it’s a problem,” Ralston says. “If the boss is telling you your job performance isn’t up to snuff, or your spouse notices an issue, it’s time to seek medical advice.”

Where to Go

Some patients first approach their family doctor for help, but many people don’t have a primary care physician, Fulop says. Instead, they may call their insurance company or a sleep center directly. Khan says sleep studies and treatments for sleep disorders are covered by health insurance.

There are numerous private and hospital-affiliated sleep centers in Central Ohio. OhioHealth alone has 11 sleep labs with four to six rooms each. Fulop says having a center close to home has proven to be a major factor in people’s choice to seek help.

“Sleeping away from home overnight is an inconvenience,” he says. “It’s important to find out what the sleep problem is, but life is still going on at the same time. Finding a place that is close to home or close to work helps them pull the trigger. They can come here after stopping at home to take care of the family, and even go right to work in the morning.”

Many people are nervous about the experience, but physicians say those fears are unfounded. “Some patients think they’ll be sleeping on a metal gurney and that people will be looking at them through a window or sitting on a stool, poking them,” Fulop says. “There is also the impression that we purposely wake you in the night.” In reality, the only time a staff member will enter the room is to replace a displaced electrode. Sleep centers offer daytime studies to accommodate second- and third-shift workers.

Patients arrive an hour or so before their normal bedtime and meet the sleep technician who will monitor the session from another room. Then, wires and sensors are attached to monitor brain activity, breathing patterns, heart rate and body movement. “When all of these are linked together, at a given moment we know what the heart, brain, oxygen and body are doing,” Fulop says.

The patient gets comfortable, reads or watches television for a while and then turns out the lights. In the morning, there should be a clear picture of how the patient’s body is performing during sleep.

Audrey Taflan had her sleep analyzed at Mid Ohio Pulmonary and Sleep Associates during two separate sessions. She says the room was like a basic hotel with exceptionally good customer service. “If I needed a fan or extra blankets, they would bring them,” she says. “It was simply a large bed with a nightstand, a chair, a mirror—not that you wanted to look at yourself once all the wires were strapped to your head and face—and a bench. It wasn’t the Ritz, but it was enjoyable.

“The first time, I was very nervous,” Taflan says. “They connected a ton of wires to my body and head. But they were very friendly and [the technician] did his best to make me feel at ease. I technically slept—the computer said so—but I felt like I was aware of everything all night long. Every time he came in to adjust a wire, I knew it.”

Taflan’s results were borderline for obstructive sleep apnea. During a second test, she says, she was much more at ease. Those results showed moderate to severe apnea. Taflan began using a CPAP (continuous positive airway pressure) machine and says she feels like a new person. Her husband is sleeping better, too.

“I’m about nine months into treatment,” she says. “I noticed small changes right away, like my headaches are gone. Nicholas can sleep through the night now without pushing me awake because I’m gasping and snoring. My blood pressure has gone down, and I’m no longer on my anxiety medication.”

Taflan says she overprepared for her first sleep study, taking along cute pajamas, toiletries, a hairdryer and a change of clothes to shower on-site the next day. The second time, she wore jogging pants and an oversized T-shirt suitable both for sleeping in and for driving home. “I skipped the change of clothes and just brought my toothbrush and slippers,” she says.

Home sleep studies may be possible in cases where sleep apnea is almost certainly the culprit. Khan says people generally choose that route when possible. “The only drawback is that it measures breathing only,” she says.

During a home study, patients affix the monitors themselves and sleep in their own bed. The equipment measures airflow in and out of the nose, as well as the effort being made to breathe. Other factors measured during an overnight test at a sleep center, such as leg movement and body position, are not part of the at-home test. “The home study can underestimate the apnea, but, for the most part, it is a really good test,” Khan says.

Treatment Options

Regardless of where a sleep study is performed, a physician specializing in sleep medicine, pulmonary issues or the like analyzes the results. Once a diagnosis is made, the recommended treatment may vary significantly based upon the patient’s needs. Treatments for apnea are often easily implemented.

Ralston says the CPAP machine is effective for 95 percent of patients. The user wears a mask while sleeping, and a constant stream of air keeps the person breathing properly and allows deep, restorative sleep to occur. Some patients find the mask uncomfortable at first, he says.

Another option may be a removable oral appliance or dental device, which realigns the jaw to keep the airway open during sleep. It is effective for 70 percent of patients, although some may experience jaw discomfort. The appliance also has to be custom fitted.

A third option is surgery to remove parts of the soft palate and tonsils, clearing more space for air to move freely. That procedure is effective for 50 percent to 60 percent of patients, Ralston says. Doctors typically opt for the least invasive option first.

“Sleep affects everything: your vitality, your motivation and your ability to excel personally and professionally,” Fulop says.

Lack of sleep can descend into a downward spiral. “Poor sleep leads to poor choices,” he says. “We may drink more caffeinated beverages to stay awake, make unwise food choices and gain weight, which leads us to sleep even more poorly.”

Sleep disorders can have effects that reach much further than feeling tired at work tomorrow. Apnea, for instance, can lead to irregular heartbeat, stroke, dementia, heart disease, high blood pressure and death, Fulop says.

Many patients don’t see a problem with their sleep deprivation, but life looks very different on the other side of treatment, Ralston says. “It improves your mood and your outlook on life,” he says. “Most patients notice a marked improvement.”

Ralston says some spouses jokingly ask if the CPAP machine could be adjusted to be a little less effective, because suddenly their husband or wife has almost too much energy.

“The typical thing you hear is that people realize they were missing out on their lives, and now they want to catch up,” Ralston says. “They can take this newfound energy and apply it to their lives, doing all the things they missed out on before because they were too tired.”

Kristin Campbell is a freelance writer.