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.