Obstructive sleep apnea (OSA) is a serious illness. If you suspect that a patient may have it, do them a favor and order a sleep study to confirm. Left untreated, OSA leads to heart attacks and strokes, and it has associations with other conditions including diabetes, hypertension, and dementia.
To be diagnosed with OSA, a patient has to stop breathing for at least a 10-second period, a minimum of 5 times per hour. I have seen patients who stop breathing over 100 times an hour! Can you imagine how someone might feel if they stop breathing that many times? Each time they have an apneic event, they experience arousals in their brain as their brain attempts to wake them so they can breathe. Think about how you might feel if someone poked you in the side 100 times an hour. You would have an arousal in your brain and then go back to sleep, but you would feel miserable in the morning from a lack of deep sleep. This is what a patient with severe OSA feels every day. Sometimes the only complaint a family member may have about their loved one with OSA is that they are “grouchy all the time.”
Patients with OSA will likely experience oxygen desaturation during events and may wake complaining of headaches. Remember this pearl: if your brain is not getting oxygen, it hurts. Also, patients’ headaches in general may worsen. Patients with chronic headaches should be evaluated regardless of whether they wake with headaches or not.
Forgetfulness is another sign of undiagnosed OSA. In deep sleep, memories are consolidated each night. If a patient is not getting deep sleep or they have interrupted sleep, then they are not going to remember things as they would normally. Common complaints are not remembering where they put their keys (or other small objects) and forgetting people’s names.
Patients with OSA and diabetes may have HbA1c levels that are all over the place because insulin is regulated during sleep. Patients with OSA who have uncontrolled hypertension should be evaluated as well; they may be having problems due to the adrenaline secreted in response to apneic events.
Remember, it is not only is the patient who experiences problems due to OSA – often, the first complaint comes from their partner who is not sleeping because of their spouse’s loud snoring. Patients’ spouses are often the first to notice apnea, although the patients themselves sleep through these events and are unaware of what is occurring.
Dry mouth, daytime sleepiness (despite being in bed adequate hours during the night), and depression are other symptoms of OSA.
When diagnosing OSA, consider different patient populations. Not every patient with OSA is overweight. OSA often goes undiagnosed in women, even though women after menopause have the same risk as men. Some patients have an increased risk for OSA, including those who smoke and those who have asthma, hypothyroidism, or Down syndrome.
Take time to assess a patient’s sleep quality at every visit. We spend one-third of our lives asleep, and it is important that we get the best sleep possible in order to repair our bodies. Remember that patients with OSA typically don’t have problems falling asleep; they are often chronically sleep deprived due to poor sleep quality. Some patients think that if they are falling asleep quickly, then they don’t have a sleep issue.
Educate your patients about the risks of untreated OSA, and remember to ask more questions if the patient complains of these other symptoms that may indicate apnea.
Sharon M. O’Brien MPAS, PA-C, is a practicing clinician with an interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.