Is snoring disrupting more than your partner's peace and quiet?
Do you wake feeling refreshed every morning?
Are you feeling more stressed and tired than you used to?
Any of these signs and many more, could be indicative of compromised breathing while you are asleep. This is known as sleep-disordered breathing or obstructive sleep apnoea (OSA). Good quality sleep is the foundation of all health. Without it your health and well-being and enjoyment of life will eventually suffer. Sleep is now recognised as one of the three pillars of health, alongside diet and exercise.
What is Sleep?
Scientists used to think that sleep was simply a switching off of consciousness from the world, but it is actually when the brain and the body get on with the daily maintenance of keeping you well. Without good quality restorative sleep, your health and well-being will start to suffer. It can creep up insidiously. You may not even notice the changes, or you may conclude that you are just stressed or getting older. Then again, you may be so used to feeling subpar that you think it’s normal.
What is sleep-disordered breathing or sleep apnoea?
Sleep Apnoea occurs when a person’s airway closes during sleep. When we go to sleep, the normal muscle tone that keeps us upright and functioning during the day switches off and gravity takes over. Some people have airways prone to collapse during sleep due to poor jaw development, a large tongue, bad posture, or weight gain. These people have a higher risk of suffering from sleep apnoea.
Sometimes airway collapse, partial or complete, can occur more than 40 times an hour. If it happens more than five times an hour, it is indicative of sleep apnoea.
As you can imagine, not being able to breathe is extremely stressful to the body. Blood pressure and heart rate see-saw throughout the night. The brain gets roused out of the deeper, restorative sleep, and sleep turns into a battle of survival rather than rest and recovery. This can markedly affect how you feel during your waking hours. Sleep should be a time for calming the heart and blood vessels, but untreated sleep apnoea causes cardiovascular stress all night.
Consequences of poor sleep
Sleep apnoea doesn’t simply mean you’re tired and you snore. It is implicated in a great number of medical conditions plaguing society, including:
- High blood pressure
- High cholesterol
- Heart disease
- Diabetes
- Cancer
- Headaches
- Depression
- Tiredness and sleepiness
- Difficulty concentrating
- Loss of enjoyment of life
- Weight gain / difficulty losing weight
- Gastric reflux
- Frequent night time urination and bed-wetting among children
- Erectile dysfunction and loss of libido
- Glaucoma and macular degeneration
- Alzheimer’s disease and dementia
- ADHD and autism
- Chronic pain
Untreated sleep apnoea has significant health consequences. The most serious damage is to the heart and blood vessels.
- People with sleep apnoea are at high risk of sudden death from heart attack or stroke.
- Severe sleep apnoea increases your risk of death from any cause 3.8 times. Sleep apnoea is a proven cause of high blood pressure.
The chance of premature death over a 16-to-18 year period worsens with sleep apnoea. This is demonstrated in the chart below. 1 The study found that people with severe sleep apnoea had a much higher risk of dying of any cause than people with no sleep apnoea:
- No sleep apnoea: 5% death rate
- Mild sleep apnoea: 10% death rate
- Moderate sleep apnoea: 15% death rate
- Severe sleep apnoea: 42% death rate
Pervasiveness
Even if one can’t personally relate to these symptoms, police encounter the consequences of them every day. In fact the police force may be unique in this pervasiveness into all facets of life. From personal health and well-being, to enjoyment and quality of life, to the quality of family and work place relationships. Most people are subject to those challenges but very few encounter the unpredictable, life affecting incidents thrust into the working life of police.
Prevalence
A study undertaken in 1993 demonstrated that 9% of women and 24% of men had enough airway collapses every hour of sleep to be diagnosed with obstructive sleep apnoea, 2 a sleep-breathing disorder. A more recent 2015 study found that number had increased to 83% of men and 60% of women between the ages of 40 and 70. 3 Of these, 50% of the men and almost 25% of the women fell into the more significant moderate to severe OSA categories.
How many times should one’s airway collapse during sleep? In reality, none, however less than 5 is considered normal. It isn’t normal, it’s just that the health consequences of less than 5 are usually less impactful. On the other hand, how many airway collapses does it take for someone to die from it? Only one – the one they didn’t wake up from.
Snoring
There are many forms of compromised breathing while you sleep. The most common one is snoring. Snoring is a sign of loaded breathing - difficulty getting the air from the outside, into your lungs. Snoring can occur alone (known as primary snoring) or as a sign of obstructive sleep apnoea (OSA).
Even primary snoring is detrimental to your health and has been shown to lead to obstructive plaques developing in the carotid arteries in the neck. Snoring can also have very serious consequences during pregnancy leading to premature birth and life threatening pre-eclampsia in the mother. Snoring in children is never normal and needs immediate attention. If you hear snoring in either an adult or a child, the air is struggling to get into the lungs. It is not normal and it is not healthy but the good news is it can be treated. Your dentist with special training in treating sleep breathing disorders is a good place to start.
Obstructive sleep apnoea
Snoring can also be a sign of obstructive sleep apnoea, although you can have sleep apnoea and not snore . For people with OSA, their airway is completely or partially collapsing repeatedly while they are asleep. This stops the exchange of oxygen and carbon dioxide leading to oxygen depletion and carbon dioxide accumulation, both of which have very serious immediate and long term health consequences. Essentially people with OSA are suffocating in their sleep.
To recover from the collapse, the brain has to partially rouse, disrupting the restorative function of sleep and this process is repeated anywhere from 5 to 100 times every hour, all night long, every night, while they sleep. No wonder people with OSA usually do not wake feeling refreshed! Blood pressure and heart rates surge up and down in response to these collapses. No wonder OSA can lead to high blood pressure.
If you suffer from any of the above conditions or symptoms, obstructive sleep apnoea should be ruled out. Diagnosis is determined by a sleep physician and by undergoing a sleep study, known as a PSG (polysomnogram). This study is usually done overnight in a sleep centre but may also be available to be done in your own bed at home, if necessary. If you suspect that you have sleep apnoea, a referral to the sleep physician via your GP can be arranged. If you doubt that you have sleep apnoea, a sleep screening, which is done in your own bed and may be available through your dentist with advanced training in treating sleep breathing disorders, may be possible as a first step. The purpose of the sleep screening would be to rule out sleep apnoea or identify you as being at possible risk to having sleep apnoea.
The sleep screening and / or the PSG will quantify the number of times your airway collapsed every hour while you are asleep. It calculates the total number of collapses then divides it between the number of hours of sleep to come up with the apnoea-hyponoea index - AHI. The perfect AHI number is 0 however less than 5 is considered normal. With an AHI >5, a sleep breathing disorder is likely. If it is >30, this is considered severe sleep apnoea and your health risk is likely to already be compromised. An AHI between 5 to 15, and 15 to 30 is demarcated as mild and moderate sleep apnoea, respectively.
The terms mild and moderate can infer a lesser need to act upon the diagnosis however the opposite is true. An AHI >5 means that you already have sleep apnoea. The good news is that the lower the score, the more chance there is that the problem can be managed successfully to significantly decrease your risk to developing the serious health consequences that accompany having severe sleep apnoea. It also means that more treatment options are open to you.
Upper Airway Resistance Syndrome and Insomnia
Another group of people is highly symptomatic of having poor sleep but when you test them for sleep apnoea, their AHI comes back <5 and their sleep study comes back 'normal'. Common symptoms include
- Significant tiredness yet difficulty falling to sleep or staying asleep. (insomnia)
- Headaches
- Chronic pain
- TMJ pain and temporo-mandibular disorder (TMD)
- Difficulty concentrating
- Irritability
- Brain fog
- Highly stressed and feeling on edge
- Depression
- Previous diagnoses of
- Fibromyalgia
- Irritable bowel syndrome
- Chronic fatigue
- Migraine syndrome
- Tension headache syndrome
More subtle signs of physiologic stress during sleep can be detected in the sleep screening or PSG and may leave clues, along with the symptoms that UARS is a possible cause. Your dentist with advanced training in the physiologic approach to treating sleep breathing disorders may be able to provide assistance in the management of possible UARS and substantially eliminate these symptoms.
In UARS, the sympathetic nervous system (the stress mechanism of the body) is on such high alert, that it does not permit the collapse of the airway when it detects that the airway is under threat. Instead it causes the partial arousal from sleep before the airway collapses hence significantly fragmenting the restorative function of sleep. This leaves sufferers highly symptomatic (and miserable) yet without an obvious organic cause of their disability. Left untreated, patients with UARS suffer needlessly and often lose hope of ever feeling normal again.
Treatment Options
The CPAP Machine has been the primary treatment for sleep apnoea since 1981. It was invented by Australian doctor and researcher, Professor Colin Sullivan from Sydney. It has saved and improved the quality of many thousands of lives around the world.
It is the first line of care for severe sleep apnoea and for patients with serious health issues, and is a very effective treatment. Some people have difficulty adjusting to and managing the CPAP. In these instances, a dental sleep appliance is much better than no treatment at all.
Sleep breathing disorders are endemic in society and the sleep fragmentation they cause has serious health consequences, yet they are both largely under-diagnosed and under-treated. At least 80% of people with sleep apnoea are unaware of it. Sleep disordered breathing affects men, women and children, the young, middle-aged and elderly. The only way to be sure is to be tested and if it comes back positive, effective treatment options are available.
The treatment needs to be tailored to the individual, and needs to be well tolerated and comfortable. One of the many possible options and one with excellent comfort and compliance (continuous nightly use) and treatment outcomes is a custom-made dental sleep appliance to support your jaw and airway. Speak to your dentist with advanced training in the physiologic approach to treating sleep breathing disorders to see if this option may be suitable for you.
Screening Questions
Do you snore?
Does your snoring bother others?
Has anyone told you that you stop breathing during your sleep?
Do you often feel tired, fatigued, or sleepy during daytime?
Do you wake and not feel refreshed?
Do you fall asleep as soon as your head hits the pillow?
Do you have trouble getting to sleep or staying asleep?
Do you get up to use the bathroom during the night?
Do you frequently fall asleep in front of the television?
Do you have or are you being treated for high blood pressure or diabetes or high cholesterol?
Have you ever had angina, a heart attack or stroke?
Do you have or are you being treated for depression?
Do you have gastric reflux?
Do you ever wake with a headache?
Does your jaw click or did it in the past?
Do you get neck pain?
Have you been told that you grind your teeth?
In Conclusion
Unfortunately people are going to continue to fall asleep while driving, over react to incidents and perpetrate violent acts, make poor decisions and mix drugs and alcohol. Nothing less than a huge national awareness campaign on the importance of great quality sleep will make an indent into this carnage, leaving police to mop up the all too often, tragic outcomes. The aftermath, sadly, is inherent in the nature of the job.
What you do have moderate control over though is your own health and well-being, your family and work relationships, the quality of your executive functioning, decision-making and coping abilities. Sleep apnoea robs you of both the quality and quantity of your life. And seeing as we only have one life to live, and that we spend one-third of that asleep, optimising the quality of that sleep should be a high priority. Restorative sleep ranks on an equal par for good health with diet and exercise. In fact, good quality sleep is the foundation of all health.
Optimum sleep can restore and enhance your personal daily outcomes. And, in case you have any doubt, you are worth it!
This is written with gratitude and respect for the importance and dedication of our Australian Police Force by Dr Anne-Maree Cole B.D.Sc MScMed (Sleep Medicine)
AUTHOR
Anne-Maree Cole, BDSc, MScMed, graduated
from the University of Queensland, Australia, with honours in dentistry in 1982. In 2014, she completed a master’s degree in sleep medicine from the University of Sydney. Her practice
in Brisbane, Australia, is limited to the treatment of patients with craniofacial pain, TMD, obstructive sleep apnoea and sleep-disordered breathing and the prevention and treatment
of these problems through various techniques including arch development and orthopaedic orthodontics using a balanced physiologic approach. Dr. Cole lectures nationally and internationally on sleep-disordered breathing, TMD and jaw development orthodontics. The dentists at James Street Dentists are qualified in treating sleep breathing disorders and can take care of all your dental needs.
References
- Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31(8):1071-78.
- Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. New England Journal of Medicine 1993;328(17):1230-35.
- Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. The Lancet Respiratory Medicine 2015;3(4):310-18.
