What you should know about sleep apnea from The Doctors

Three myths about a common disorder that can rob you of rest and good health

Myths About Obstructive Sleep Apnea: E.R. physician Dr. Travis Stork explains how The Doctors' latest article in USA Weekend Magazine focuses on common myths about obstructive sleep apnea.

Snoring means you have sleep apnea: That’s one commonly held belief about the condition that’s just not true. Lots of people snore — some estimates say up to half of Americans do it at one point or another. But there’s the harmless “sawing of logs,” and then there’s the snoring associated with obstructive sleep apnea, which is often characterized as loud and chronic, gets worse when you’re sleeping on your back, and — most telling — is peppered with silent pauses, sometimes followed by snorting or choking sounds. These pauses are the midsleep breathing interruptions that define apnea: They last anywhere from a few seconds to minutes and can occur 30 times or more an hour. Here are three more myths about sleep apnea, and the facts behind the fiction:

MYTH: It's not that serious.

The combination of not-restful sleep and reduced blood oxygen levels from disrupted breathing can be tough on the body. It can strain your heart and cardiovascular system, which may increase your risk of hypertension and heart disease, as well as congestive heart failure, cardiac arrhythmia or stroke. Findings from new research published in theJournal of the American College of Cardiology suggest sleep apnea may also boost the risk of sudden cardiac arrest. The disorder can also mess with your mood and memory and leave you feeling exceptionally drowsy during the day, which puts you at a higher risk for work-related accidents and automobile accidents.

MYTH: Only older adults develop sleep apnea.

Though it’s true that risk increases with age, anyone can develop sleep apnea — even children. Men are more likely than women to have apnea; so are people who are overweight or have small airways in their noses, throats, or mouths. Family history, smoking and ethnicity may play a role as well. Recent, preliminary research also suggests a link between asthma and obstructive sleep apnea: According to scientists who worked on the study, people with asthma were about 70 more likely to develop apnea eight years later.

MYTH: I'll have to sleep with a breathing mask.

Continuous positive airway pressure (CPAP) machines — which gently blow air through a mask to help keep airways open while you sleep — are a common and effective treatment for moderate to severe apnea, but if you can’t tolerate the devices, there are other options. Your doctor may suggest different types of airway pressure devices; researchers also are exploring a promising new treatment for more serious cases that involves implanting an electrode to help stimulate the upper airway. For mild cases, wearing a mouthpiece designed to keep airways open may help, and so could changes in living habits, such as losing weight, sleeping on your side or avoiding alcohol and medicines that make you sleepy.

Advice About Sleep Deficiency in Midlife, Part 1

By THE NEW YORK TIMES

Published: September 25, 2013 

Nearly 200 people sent questions about sleep to Orfeu Marcello Buxton, a neuroscientist who studies chronic sleep deficiency in the workplace and home and how it contributes to disorders like obesity, diabetes and cardiovascular disease.

Dr. Buxton is an associate neuroscientist in the Division of Sleep Medicine in the Department of Medicine at Brigham and Women’s Hospital in Boston, as well as anassistant professor at Harvard Medical School and the Harvard School of Public Health. He received his doctorate from Northwestern University in Evanston, Ill. (Note: Dr. Buxton is a researcher, not a physician, and he emphasizes that his responses should not take the place of recommendations from your health care provider.)

More responses will be posted next week. Because of the volume of questions, not all may be answered.

Disclosure statement: Dr. Buxton’s current research is financed by several branches of the National Institutes of Health. He is a consultant to the Harvard School of Public Health Center for Work, Health and Well-being and is on the scientific advisory board for Matsutani America (a dietary fiber supplement manufacturer). He has served as an expert witness for Dinsmore L.L.C., received speaking/consulting fees from Takeda Inc., and was the principal investigator on investigator-initiated research financed by Cephalon Inc. (now Teva) and Sepracor Inc. (now Sunovion).

Introduction

Thank you to all readers who commented and submitted questions. The breadth of the questions speaks to the many different ways that we sleep, and how our expectation about sleep, and our sleep patterns and habits can vary with circumstances and our environment, and across the course of life.

Healthy Sleep in Midlife

Q. I go to sleep fairly early (8:30 p.m.) because I am exhausted, yet I wake up around 2:30 or 3 a.m. and cannot get back to sleep. I used to sleep much longer and arise more rested. Is this probably just age? Are there things I can do to help myself sleep longer? — CM, Placitas, N.M.

A. Many readers addressed directly or indirectly the question, “What is ‘normal sleep’ in midlife?” Setting aside the possibility of a sleep disorder (some of which are addressed below), normal sleep has a physiological basis, but also a cultural basis (see below on the relatively modern emergence of an expectation of a single consolidated night’s sleep). What we might consider normal sleep in midlife varies depending on individuals and their circumstances.

Typical advice has been to get a full eight hours of sleep, but this is the “tyranny of the mean.” Our individual sleep need is roughly the same across adulthood, though as discussed below (“Sleep and Aging”), the amount of sleep we need may decline slightly as we age. For most adults, routinely sleeping seven to nine hours per night regularly is appropriate for optimal functioning and health. That said, there will be some people who need less, and some who may need more sleep; it’s just that there are far more of us getting less than we probably need (the United States average is just above seven hours a night, and the proportion of short sleepers is increasing). Information is available from the Harvard Division of Sleep Medicine on the benefits of healthy sleep and getting enough sleep, including a “sleep makeover,” and 12 simple steps to improving your sleep.

So how can you tell if you are getting enough sleep at this time in your life? I have a nonclinical litmus test. First, pay off your sleep debt by getting plenty of extra sleep for a few weeks. Vacations outside of our normal pressures can work well for this. Then, begin going to sleep and waking up at about the same times each day, and you will find that your individual number may emerge — the number of hours of sleep after which you wake up and generally feel refreshed, without stimulants. The test is: can you sleep this amount, get up without an alarm clock (except for backup to avoid worrying about missing a morning obligation), and feel good? Bonus: someone else may also report you are (even more) pleasant?

As you can imagine, maintaining healthy sleep is a lifestyle and is not achieved through a quick fix. We don’t go to the gym once and expect immediate fitness, or eat salads for one day and expect leanness. Getting enough sleep gives more energy for vigorous exercise and improves healthy food choices. But where is the time for all this, you might say? To achieve healthy sleep, prioritize your health and recognize that being your best, rested self is more important than something else like watching television or mobile-device screens, especially in their most ad-infused forms, or social media indulgences that don’t bring real joy. The three pillars of health (diet, sleep and exercise) can help everything else go better in our lives, especially the most important things like our relationships and true passions.

Sleep Apnea

Q. How we can differentiate between normal snoring and sleep apnea? — Jnanawala, Surat, India

A. Some readers asked directly about the symptoms of sleep apnea and snoring, or described extremes of daytime sleepiness that might suggest sleep-disordered breathing or other sleep disorders that would be good to rule out. Sleep-disordered breathing results in a lack of sufficient oxygen being taken into the lungs and throughout the body, usually because of a constriction of the airway, but possibly also related to structural issues or sometimes breathing centers in the brain not working ideally. Sleep-disordered breathing also causes frequent interruptions and awakenings during sleep.

Symptoms of sleep-disordered breathing include excessive daytime sleepiness, choking or gasping during sleep and sometimes morning headaches because of low oxygen during sleep. In response to falling oxygen levels in the blood (and or rising carbon dioxide levels), a brain “arousal” lightens sleep and a gasp or deeper breathing takes in more air. Risk factors include having a greater than 17-inch neck size, obesity, being male and a family history of apnea. But it is possible to have none of these factors and have sleep-disordered breathing. Snoring is much more common than sleep-disordered breathing, and snoring doesn’t necessarily mean one has sleep-disordered breathing. But the cessation of breathing for more than 20 seconds during sleep is an indicator of sleep apnea. A diagnosis of sleep apnea involves a sleep test at a sleep clinic or in the home.

There are a variety of treatment options, but the most common is an air pump and a mask that is worn during sleep to provide enough extra air pressure to overcome the obstruction. These work best if worn the entire night.

The Harvard Division of Sleep medicine has accessible and engaging content on sleep apnea here. Detailed patient information about sleep-related breathing disorders and treatment options is available from the American Academy of Sleep Medicine.

Insomnia

Q. What can be done about middle-of-night insomnia? I go to bed at 9:30 or so, exhausted and fall asleep in 2 seconds. Then I wake up anywhere from 1:30 to 4 a.m., and cannot fall back asleep for hours if at all. It turns the days into endurance events. Once in a great while, I get a full seven to nine hours and feel magnificent. There is no pattern to it and I cannot make it happen. I cannot take my 1:30 a.m. start of the day. Don’t want to take pills to sleep. — xojoyox, Brooklyn

A. Difficulty getting to sleep or staying asleep on a regular basis (three or more times per week for at least a month), and a complaint about this sleeplessness causing other problems, is chronic insomnia. Acute insomnia usually has a clear precipitating cause, like stress, anxiety, conflict, grief or a medical condition or medication with side effects. In contrast, chronic insomnia can have less obvious or long-past precipitating factors. Chronic insomnia is thought to be perpetuated by established habits and expectations about sleep, as well as potential brain neurotransmitter or brain system changes that cause the brain to be hyperaroused during sleep, or in other words, cause the wake centers of the brain to be stuck in the “on” position. Chronic conflict at work, harassment at work, or stress at work in general can contribute to insomnia.

The inability to sleep in the middle of the night is an especially difficult form of insomnia on the minds of many of us in midlife. Sleep maintenance difficulty is, for example, more strongly related to diabetes risk than short-sleep duration or difficulty getting to sleep. But it’s important not to overly worry about this because this rumination can worsen insomnia.

There are several active steps to take.

Try to understand what might be causing the awakening: is there a regular interruption like noise that is contributing to this? Snow days are so peaceful and restful when airplane flights are canceled and snow dampens traffic and other sounds, but only until the snow plows grind down the street. Pets and bed partners can be a source of potential interruptions.

If it seems that the awakenings are internally generated, start with an assessment of sleep disruptors, like excess caffeine; or a sleep environment that is too bright, hot, cold or noisy.

If these things don’t work, it may be time to talk to your physician about potential medical causes of insomnia, like medications, sleep disorders (sleep apnea, restless-legs syndrome) and medical and psychiatric causes.

Additionally, consulting a sleep specialist may help. New formulations of F.D.A.-approved medications with short half-lives may be useful in treating middle-of-the-night insomnia — in the short term. In the long term, behavioral treatments to improve sleep, including cognitive behavioral therapies or mindfulness practice can improve sleep, and have a sustained impact after the cessation of active treatment. A lot of work remains to be done to determine the effectiveness of these various pharmacological and behavioral treatments, especially head-to-head comparisons, but promising ones are available now.

For useful patient information on all manners of sleep disorders, include information from the American Academy of Sleep Medicine, which includes a Find a Sleep Center tool.

Sleep and Aging

Q. What can a 65-year-old woman, who ever since menopause wakes up 10 times a night, do to get a good night’s sleep? — Bonnie Rozanski, Lawrenceville, N.J.

A. Many of us are concerned about sleep changes with age. In general, sleep is much deeper when we are very young — thus the expression “sleeping like a baby.”

Insomnia reports are thought to be more common in women than men in midlife, and further increase in peri-menopause and post-menopause.

There are several aspects of sleep changing with age, including our response to the sleep environment.

External stimuli are less likely to awaken us during this deep, non-R.E.M. or slow-wave sleep. The amount of deep, slow-wave sleep declines over the first several decades of life. In the third decade of life the amount of this deep sleep decreases rapidly, and thus we become more likely to be awakened by external stimuli like sounds. Also, even in healthy sleepers, as we grow older it can take a bit longer to fall back to sleep once we are awake. This causes us to be awake for longer periods of time, increasing our chances of remembering awakenings during the night that might otherwise be so brief as not to be recalled the next day. We also exhibit more awakenings during the night. It also appears that as we age we have a reduced capacity for sleep, or potentially, even a reduced “need” for sleep.

It is important to remember that frequent and longer awakenings in midlife are fairly common. Bonnie and other readers with similar questions about generally sleeping better did not express a concern with some aspect of daytime functioning, like excessive sleepiness. A sleep-related complaint might warrant a closer look, but adjusting expectations and not worrying about sleep unnecessarily is also part of sleeping better. If you think that your daytime function is not optimal because of a sleep problem, and the 12 simple steps to improving your sleep, which you can read here, don’t seem to help, you may want to consult your physician and then a sleep specialist.

More answers from Dr. Buxton will be posted on Booming on Oct. 2.

Pilots snoozed at 30,000 feet in cockpit of 300-passenger plane

By Thom Patterson, CNN

updated 6:47 PM EDT, Thu September 26, 2013

UK probes whether pilots slept at same time

(CNN) -- Cruising at 30,000 feet, pilots snoozed in the cockpit of a 300-passenger airliner en route to Britain last August, UK aviation authorities told CNN on Thursday.

A spokesman for the UK's Civil Aviation Authority tells CNN that the Airbus A330 incident occurred while the aircraft was operating on autopilot on a long-distance flight. The CAA wouldn't reveal any other details of the flight, its route or its destination airport.

Sources told CNN's Richard Quest the airline is Virgin Atlantic. The airline in a statement said, "Virgin Atlantic can confirm no safety reports have been received about pilots falling asleep simultaneously whilst in control of an aircraft."

British pilots are allowed to sleep while in the cockpit under certain circumstances.

The August 13 incident appears to be the result of bad scheduling by the airline, said the CAA spokesman Richard Taylor. The pilots reported having only five hours of sleep over two nights "due to longer duty period with insufficient opportunity to sleep," the CAA report states. "Both crew rested for 20 minute rotations and fell asleep."

The aircraft apparently arrived at its destination safely. It's the first British incident of its kind in two years, said Taylor. He said it's unlikely the pilots will be disciplined.

"You can't have five hours of sleep in two days," says veteran airline pilot and aviation consultant Mark Weiss. "That doesn't work."

Fatigue ranks among the most sensitive issues in the pilot community. Rules surrounding sleep and relief crews vary from country to country.

Jim McAusian, general secretary of the British Pilots Association, used the incident to blast the CAA's record on pilot fatigue in a statement Thursday, accusing it of being "far too complacent about the levels of tiredness among British pilots and failing to acknowledge the scale of the underreported problem."

Next week, the European Parliament is expected to vote on new EU rules regulating pilot flying hours. McAusian said the proposed rules will increase "tiredness among pilots and the risk of dangerous incidents."

In the U.S., flights longer than eight hours require a relief pilot on board to take over so pilots can take a break to sleep. If the flight is scheduled to last more than 12 hours, an additional relief pilot must be added.

Should cockpit sleeping be allowed?

Believe it or not, some experts say pilots sleeping at the controls isn't always dangerous.

Aviation rules in some nations allow pilots to nap in the cockpit during ultra-long-haul flights -- across oceans, for instance. Rules vary, but generally, the sleeping pilot must be supervised by another pilot during the naps. There are also backup alarm systems in place to awaken pilots if an emergency arises.

The CAA refused to tell CNN whether it has evidence that both pilots were asleep simultaneously. The report is ambiguous, the agency says. If both pilots at the controls had fallen asleep simultaneously, Virgin Atlantic would be required to file a report with the CAA. The airline told CNN that it has no record of both pilots falling asleep at the same time.

It's possible the pilots were resting one at a time under an authorized cockpit napping program.

Among U.S. pilots, cockpit napping violates FAA rules. But some experts, including Weiss, favor the idea. "This is a personal belief," he said, "but I would rather have somebody take a nap during a cruise part of a flight so that pilot would be at peak performance during a high-traffic situation or a landing."

Unauthorized cockpit napping among U.S. pilots isn't "that prevalent," Weiss says, "but that's not to say it doesn't happen."

Curt Graeber, who was with Boeing for 19 years, headed a NASA/FAA study that recommended the FAA allow cockpit napping. But the FAA has never adopted the idea.

"I think it's political," he told CNN. "I guess it's difficult to tell the public that the captain is asleep on the flight deck."

"Everyone I talk to who uses it says it's a stopgap measure to improve safety and reduce the risk of sleep loss."

Studies have shown, Weiss says, that taking a 20-minute nap will allow pilots to regain energy. "It's not a bad idea to allow pilots to take short naps," he said.

Instead of allowing in-flight napping aboard U.S. airlines, the FAA has mandated that long-haul routes include relief pilots and special onboard sleeping quarters that must be available for the flight crew.

Other sleeping incidents

Of course the UK sleeping incident revealed Thursday isn't the first of its kind. Last February, the Dutch airline Transavia said it had launched an investigation after a Boeing 737 pilot was locked out of the cockpit and his first officer was later found asleep at the controls. The sleeping pilot had been left alone at the controls while his co-pilot took a bathroom break.

The incident took place in September 2012, when the airliner was flying from Greece to the Netherlands, a top Dutch safety investigation agency said. The 737 landed safely in Amsterdam as scheduled.

'More than half' of pilots have slept while flying

More than half of pilots have fallen asleep while in charge of a plane, a survey by a pilots' union suggests.

Of the 56% who admitted sleeping, 29% told Balpa that they had woken up to find the other pilot asleep as well.

The survey comes after it emerged that two pilots on an Airbus passenger plane were asleep at the same time, with the aircraft being flown on autopilot.

Balpa is campaigning against changes to flight-time regulations, which are to be voted on by the European Parliament.

On Monday, new rules which include allowing pilots to land an aircraft after being awake 22 hours, as well as being able to work seven early starts in a row rather than the current three, will be put to a vote.

'Biggest threat'

The Civil Aviation Authority (CAA) supports the proposals and said the incident on 13 August where both pilots were asleep was an isolated one.

In that case, a report found the pair fell asleep after both had only five hours sleep in the previous two nights.

But of the 500 commercial pilots surveyed by Balpa, 43% said they believed their abilities had been compromised at least once a month in the last six months by tiredness, with 84% saying it had been compromised at some stage during the past six months.

And 49% said pilot tiredness was the biggest threat to flight safety - three times more than any other threat.

The plane was at 35,000ft when the pilots fell asleep

The union said its members, who were the pilots that were surveyed, overwhelmingly worked for British-based airlines.

Balpa wants MEPs to back a motion which would require the European Commission (EC) to withdraw the proposed changes and to have them scrutinised by scientific and medical experts.

Its general secretary Jim McAuslan told BBC Radio 4's Today programme that the EC was trying to get a level playing field across Europe but it had instead diluted UK standards.

"This is deeply worrying for everyone concerned.

"The CAA has been completely complacent about these rules (for pilots to report sleeping incidents).

"It suggests to us that they are ignoring this problem. This is the second time in two years that the survey has run that has shown consistent figures with pilots falling asleep."

'Increase safety'

House of Commons Transport Committee chairwoman Louise Ellman said: "I agree with Balpa's concerns that the proposed changes to EU rules could endanger air passenger safety."

She added: "We have called for scientific evidence to be used to judge just how long pilots should be awake. There is still time for the UK government and Europe to think again."

In a statement, the CAA said: "We think the new European flight time limitation regulations maintain the UK's current high safety levels, and will actually increase safety for UK passengers travelling on some other European airlines.

"This view is informed by expert opinion, based on scientific principles, operational knowledge, regulatory oversight information and research.

‪"The changes will give the CAA far greater access to airline data to help us oversee fatigue risk management."