Think Sleep Apnea is Just Snoring and Sleepiness? Think Again

Obstructive sleep apnea is an important medical breathing disorder in which one’s upper airway collapses episodically during sleep.  The lack of oxygen and the buildup of carbon dioxide in the bloodstream resulting from airway closure then provoke frequent brief arousals from sleep throughout the night, causing substantial fatigue and sleepiness during the day.

The cardinal symptoms and signs of sleep apnea are well-known:  excessive daytime sleepiness, nocturnal sleep disruption, loud snoring, witnessed breathing pauses, gasping sensations out of sleep.  However, what is not well known to the public is that there are many additional symptoms–some subtle, some not so subtle–that can be caused by or attributable to untreated sleep apnea.  If you are experiencing one or more of the following in the setting of some of the above-mentioned sleep apnea symptoms, you may want to consider seeing a doc like me.


1.  Headaches.  Many people with untreated sleep apnea have headaches, which are typically worse in the early morning or upon awakening as compared to later in the day.  Sometimes the headaches can actually cause awakenings in the middle of the night or in the morning.

2.  Nocturnal palpitations.  Because of sympathetic overactivity (hyperstimulation of the adrenalin system), untreated sleep apnea can cause people to awaken abruptly feeling like their hearts are “racing,” “pounding,” and/or beating irregularly.

3.  Night sweats.  Some people “run hot” while they’re sleeping, but sleep apnea can often cause people to sweat profusely and frequently in bed, sometimes to the point of being drenched, due to the effects of frequent brief arousals from sleep.

4.  Frequent urination at night.  This is a big one.  I can’t tell you how many patients of mine have previously undergone comprehensive urology evaluations because of multiple awakenings due to a full bladder.  This is a huge problem, one that men and woman alike often try to learn to live with for years before seeking medical attention.  Untreated sleep apnea tends to increase one’s urine production at night, and treating it often makes this problem improve or go away.

5.  Sexual dysfunction.  The association between untreated sleep apnea and erectile dysfunction and reduced libido is clearly documented in the medical literature, and sleep apnea treatment–such as with positive airway pressure (CPAP)–has been demonstrated to be helpful in improving or resolving these problems for many.

6.  Leg swelling.  Ever notice that sock line around your ankles when you take off your socks at the end of the day?  Sometimes this soft tissue swelling of the legs can be severe and painful.  Peripheral edema can be related to a number of different medical issues, sleep apnea being one.

7.  Memory problems and depression.  Think about it.  If you’re constantly awakening briefly from sleep all night every night for years, this problem can easily take a toll on your mood and your ability to concentrate and remember things.  On numerous occasions patients have visited me after having had extensive workups for dementia or depression, with treatment of their sleep apnea subsequently improving or even resolving their memory and mood problems.

8.  Difficulties losing weight.  If you’re tired and fatigued all day, you may not have the energy to exercise and burn off calories.  But in addition to this, untreated sleep apnea can impair your metabolism as well, affecting certain weight-mediating hormones such as growth hormone and leptin.  Treating the sleep apnea doesn’t necessarily make you lose weight automatically–you still have to work at it, with diet and exercise–but it may make it substantially easier to lose weight with a proper weight reduction program.

Bottom line:  sleep apnea can be associated with a surprising number of problems that initially may not appear to be related directly to your sleep.  Don’t ignore your symptoms.  The primary sleep apnea symptoms of daytime fatigue, loud snoring, and witnessed breathing pauses during sleep shouldn’t be ignored anyway, but additional problems like morning headaches or urinating a lot at night should increase your level of concern still further.

Have a great day, y’all!


R.I.P., C. Everett Koop

It’s with a heavy heart that I write this brief piece in tribute to C. Everett Koop, our nation’s former surgeon general.  He was born October 14, 1916.  He passed away peacefully yesterday at his home in Hanover, New Hampshire.  He was 96.


Dr. Koop was born in Brooklyn, New York.  He completed his bachelor’s degree at Dartmouth College, his medical degree at Cornell, and his doctor of science degree at the University of Pennsylvania.  For decades he served as surgeon-in-chief at the world-famous CHOP (Children’s Hospital of Philadelphia).  He was also a professor at Penn.  He was well-published and he developed numerous important surgical procedures.  Then, in 1981, he was appointed by Ronald Reagan as deputy assistant secretary for health and, shortly thereafter, surgeon general of the United States.  He remains the one U.S. surgeon general whose name I consistently remember.  During his tenure he steadfastly championed several important health and social issues, including AIDS awareness and the importance of smoking cessation.

Following his service as surgeon general he eventually returned to Dartmouth, where he held professorships and founded the C. Everett Koop Institute at what is now called the Geisel School of Medicine.  I met and spoke with Dr. Koop following his lectures while I was a resident there.  His personality was as colorful as his bow ties.  I thoroughly enjoyed speaking with him and hearing his thoughts regarding the direction of medicine and the politics of the administration of health care in this country.  These issues were not otherwise routinely taught to us postgraduate trainees, and no one at the time could have dreamed about how important an awareness of health care administration would be now in the 21st century, a genuine health care crisis looming as it now is.  It was abundantly clear to me that Dr. Koop honestly cared about the welfare of all Americans.  I loved his enthusiasm and his ongoing interest in teaching, despite his advancing age.

I believe the United States would benefit from more physicians like C. Everett Koop, those who have the courage to stand up for what they believe in and what they believe to be right.  He will be missed, both in the Upper Valley and way beyond.  Sleep well, Dr. Koop.

Lessons From Hanauma Bay

I readily admit that I don’t take as many vacations as I should these days.  I can count the number of days off I took last year on my two hands.  Like many of us, I find it difficult to leave my work:  what will the place do without me, after all, and how will it possibly survive?  Taking a little time away now and then is crucial for me and my family, and the older I get, the more so it becomes.  We love to travel, but more critically, there is something vitally important about getting gone for a while:  I need a good dose of new perspective from time to time, a reminder of the reality that exists beyond the walls of my clinic.  So my wife and I decided to bite the bullet and book a trip to one of our favorite relaxation sites, Hawaii.  Our whole family needed a break, we reasoned, from hard work and this dreary Seattle weather, so off we went last week to Waikiki.  During Hawaii’s rainy season, of course.


One of my favorite spots on Oahu is the acclaimed Hanauma Bay, not far from Waikiki and Diamond Head on the southeast corner of the island.  A remnant of an ancient volcano, its crescent-shaped crater is fed sea water continuously from its distal outlet, but what makes the bay truly remarkable are the huge, bountiful, finger-like shallow coral reef complexes and the multitudes of colorful sea life that take up residence there, meandering and darting through the coral structures in a beautiful, primal dance.  I’ve been to the bay several times in my younger years, and now taking my children to float above its reefs allowed me to relive that initial thrill of becoming one with thousands of bright butterfly fish, mammoth parrotfish, majestic honu (green sea turtles), delicate silver goatfish (traveling in huge schools), various surgeonfish, and countless other marine species.  Unfortunately the place is not a secret, and even in the off-season the shore sands of Hanauma Bay fill with legions of international tourists because the snorkeling is so great, but if you go early enough in the morning the beach is quiet and desolate, and for a few precious hours you and your family feel like you are the very last people on earth.


Our first swim out was memorable for more than just the fish.  The tide was high and the current unusually strong.  It was difficult to progress despite my long fins and my experience in open-water diving; I could feel my muscles tensing as I strained to lead the boys to deeper water.  Then I remembered what I constantly have to remind myself of each time I slip into the ocean:  the water is bigger than me, and it’ll do what it’s going to do, whether I’m in it or not; better to accept it for what it is and go with its flow than to fight it and waste energy.  My boys were experiencing the same and worse, splashing and fighting the water’s choppy shoreward push.  So I made us stop and stand for a few minutes, waiting for the occasional brief calm in the water for our opportunity to go out further.  In this way we eventually found ourselves swimming with thousands of fish in deeper water.

I encouraged my boys to observe the fish’s movements in relationship to the waves.  We floated quietly at the surface, observing the creatures below us.  The fish, of course, were just as subject to the slow rhythms of tidal surges as we were.  We discerned a pattern as we watched.  As the tide approached, they appeared to relax their bodies and become more bendable, like colorful oval pieces of soft rubber.  A second later, an invisible plume of water sent them tumbling, rapidly but gracefully, sometimes in unison, sometimes in all different directions and angles, but never onto or against the abrasive surface of the coral.  Then, the next moment, we felt ourselves pushed forcefully by that same invisible force.  Our reactive inclination was to resist, to push back to stay in place.  But the fish teeming beneath us taught us something.  All that struggle against our surroundings, it was utterly futile.  So we stopped struggling and forced ourselves to relax like the fish.  Flowing along wherever the tide led us, we quickly found ourselves covering more ground, encountering more fish, and enjoying ourselves more, without consuming all our energy fighting the current.

You’re asking, what does this all have to do with sleep?  Well, it often is wasted energy fighting what is natural, what is inevitable, what is bigger than you.  This is an important recurring theme in my management of insomnia (as well as my blog entries), to reverse that conditioned inclination to resist, to fight, to try hard to achieve sleep, when sleep is a natural, required biological function that need not be pushed into being.  Seeking ways of allowing it to come upon you naturally generally works better than trying to force it into you.

On a broader level, though, the perpetual lesson for me is that I am constantly surrounded by forces I’m unable to control.  The changes that are happening in health care, for example–administratively, financially, and otherwise–and the even crazier changes yet to come, I am powerless to alter or prevent them.  So again, to me vacations are great for gaining and regaining perspective.  Better to relax and keep yourself limber and flexible in preparation for the inevitable next push of the tide; you may not end up in the place you originally intended, but you’re less likely to get hurt and you might even enjoy the ride.

Hmm . . . perhaps I need to start planning my next vacation soon.  I could use all the perspective I can get.

I’m back on the mainland now, so there will be more writing to come shortly.  To my readers, mahalo!


Turn That Alarm Clock Around!

Howdy all.  I hope you had a great weekend!


Tonight I write briefly about a habit many millions have adopted as an integral part of their night-time routines:  staring at the alarm clock.

When you awaken in the middle of the night, it’s a perfectly natural impulse to glimpse at your clock.  It seems important to know how much more time you have before it goes off, or how much sleep you’ve gotten, or how many more hours you get to spend in bed.  However, for those with insomnia, this “clock-watching” can easily compound the frustration that comes with being awake in the middle of the night when you don’t want to be.

Here’s the typical scenario.  You go to bed, hoping you’re going to fall asleep quickly.  After a struggle and some tossing and turning, you finally manage to trundle off to sleep.  Suddenly, it’s 2:07 a.m.  You turn your head to view the clock.  The red digital numbers glare starkly at you, offering you a silent challenge:  “OK, now you know; so what are you going to do with the information I just gave you?”  You feel the frustration already gnawing at you as that precious sensation of drowsiness starts to ebb, giving way to an unwelcome wakeful feeling arriving way too early.  You turn your head forward to stare now at the ceiling, hoping the sleepiness will somehow return, but it’s too late.  The wakefulness that inevitably accompanies your exasperation is firmly planted now, dancing about in your head derisively as you try with increasing desperation to achieve sleep again.  A half-hour crawls by . . . or was it fifteen minutes?  Maybe you should look at the clock again to find out:  there’s that meeting you have to be fresh for, you have to get up at 6 at the latest, and you need that sleep badly to be in top form later in the day.  Should you turn your head toward the clock again?  A couple seconds of existential struggle later, you satisfy your need.  It’s now 2:11 a.m.

Does all this sound familiar?  Sure it does.  It’s happened, in one form or another, to virtually all of us (myself included) during our lives.  That urge, that need to gaze repeatedly at the clock can easily and naturally become a habit, an insomniac ritual.  And for some this ritual can, over time, get completely out of control, with an increasing need to look at the clock all the time, every several minutes, sometimes even several times per minute.  How is this not going to make you completely cray-cray?  I’ve had insomnia patients who have purchased those special clocks that actually project the time in huge red numbers onto the ceiling, so they can watch each minute of sleeplessness tick slowly away every night.  I do not advise this.

There are two problems with habitual clock-watching:  it doesn’t help, and it can often make insomnia worse.

Think about it.  Watching the clock doesn’t make the time go any faster; it doesn’t make you fall asleep any faster.  It only frustrates you, because every time you gaze at the clock you add a little bit more pressure upon yourself to perform, to achieve the sleep you so desperately want.  And the more frequently you watch the clock, the more the aggravation mounts.  You may not even be aware consciously of the frustration, but it’s there, creating more and more mental stimulation and making you feel increasingly awake and alert, at precisely the worst time of your diurnal cycle.

My advice to habitual clock-watchers:  turn the clock around.  If the alarm clock is working properly and if the wake-up time is set properly (you should check these prior to your bedtime), it will awaken you when it’s supposed to.  Get a second alarm clock that is battery-powered if you’re concerned about a power outage preventing you from awakening at the right time.  Your clock doesn’t care if you’re staring at it all night or not.  It’ll go off when it does.  Trust it to do that for you.  If you can free yourself from the psychic need to look and to try to control time when you can’t, you will only help yourself and increase the likelihood of eventually freeing yourself from the bondage of insomnia.

OK, folks, I am going to take a little breather from writing for several days.  I will be back at it in full force before long, however.  Sleep well, everybody!


How Animals Sleep

Sleep remains a mysterious thing on so many levels, but one thing is clear:  virtually every animal requires some form of sleep, or at least its equivalent.  Even the most simple creatures, like planaria, demonstrate regular periods of behavioral rest.


There are 4 generally accepted criteria for sleep universal in the animal world, and these obviously mirror how we understand sleep for humans as well:

1.  Little or no movement

2.  Stereotypic posture (most commonly lying down)

3.  Reduced response to stimulation

4.  Reversibility (permament sleep would be a problem)

Certain animal species can sleep in very unique ways, however.

Dolphins, for example, have unihemispheric “deep” sleep, in which one-half of the brain demonstrates sleep (as measured by electroencephalographic, or EEG, waveforms) while the other half demonstrates EEG evidence of wakefulness.  Such functional hemispheric disconnections may persist for minutes or hours at a time.  I find this endlessly fascinating.  Essentially, dolphins can truly be half-awake, half-asleep, perhaps to be able to swim and/or remain aware of surroundings or predators while at rest.


Various herbivores, like cows and sheep, can ruminate (chew and rechew cud) during sleep.


Many different animal species hibernate in order to reduce energy requirements in harsh environments.  These animals would include mammals (bears, bats, and marmots), certain birds, snakes, turtles, frogs, and snails.  How such animals arouse regularly from hibernation is among the many mysteries of animal physiology.


Some animals sleep in trees, both predators (like cheetahs) . . .


. . . and prey (such as baboons).


Adult giraffes generally don’t need much sleep.  It’s estimated that they get 1/2 – 1 hour of sleep per night, usually in very brief (5-minute) naps.  They may remain standing while sleeping.

Enjoy your weekend, everybody!  Cheers!

Restless Leg Syndrome Treatments


Hi all!

I’ve received numerous messages in response to my recent restless leg syndrome (RLS) post, some of which asked about treatments.  So let’s address that now, shall we?

One important thing to know, first of all, is that not all cases of RLS require treatment.  Like most other medical disorders, there is a spectrum of severity with RLS; mild cases, only slightly annoying or easily made better with a brief walk up and down the hall, may not need medications.  Me, I consider treating RLS patients whose qualities of life are compromised by the problem:  difficulties participating in activities; ongoing difficulties falling and/or staying asleep; chronic discomfort; bed partners unable to sleep because of the movements.

Typically I first explore if an RLS sufferer has iron deficiency.  Iron deficiency is quite common; it’s estimated that 1/3 of iron-deficient people have RLS.  20% of RLS sufferers have iron deficiency.  There’s a lot that is still not understood about exactly what causes RLS, but it appears that RLS is related to dysfunction associated with a specific neurotransmitter called dopamine.  Iron is a mineral co-factor associated with the production of dopamine in your brain.  I check a serum ferritin level when assessing an RLS patient.  Ferritin is an iron storage protein.  It’s known in the medical literature that ferritin levels of 50 or less are associated with an increased propensity to having RLS. Iron supplementation (such as with ferrous sulfate or ferrous gluconate) thus may be very helpful in improving RLS symptoms.

For those with RLS of unknown cause, here are the FDA-approved medications to treat RLS symptoms:

1.  Ropinerole (Requip).  This is a dopamine agonist, which means it activates dopamine receptors in your brain.  You take it by mouth.  This medication is the first FDA-approved medication for RLS treatment.  It’s available generically now, which means the potential for cost-savings.

2.  Pramipexole (Mirapex).  This is also an oral dopamine agonist medication, available generically.

3.  Gabapentin enacarbil (Horizant).  This is an extended-release tablet that you take once per day, around 5 p.m.  Unique features:  it’s not a dopamine agonist (it is the pro-drug to gabapentin); and it’s long-acting.

4.  Rotigotine Transdermal System (Neupro).  This is also a dopamine agonist medication, but the unique feature here is that it comes in a patch, which you apply once each day to the skin.

My practice is to use the minimal medication that provides the maximal effect in stopping the RLS symptoms.  The orally-dose dopamine agonist medications typically are taken in the evening.  I generally recommend that the medication be taken roughly 1-2 hours prior to the projected onset of symptoms; it’s better to try to prevent the symptoms from happening than to try to tamp the symptoms down once they’ve started.

Other medications have historically been used, including benzodiazepines, sedative agents, and, particularly in the case of severe, difficult-to-treat RLS, narcotics.  Non-medicinal treatments used over the years are legion, and include mild to moderate exercise prior to bedtime and hot baths or compresses prior to bedtime.  Avoiding caffeine and alcohol use in the evening may also be helpful; I recently had a patient whose RLS completely went away by stopping her late afternoon caffeine consumption.

No medication is perfect or without side effects.  Dopamine agonists can be associated with daytime sleepiness in some, but so can Horizant.  In addition, there is the potential for something called augmentation (a gradual worsening of symptoms due to or related to ongoing treatment), which may occur particularly in the setting of dopamine agonist use.  As always, you need to weigh benefits and risks when considering treatment, and you should have a clear, open discussion with your doctor regarding the nature and severity of your symptoms, as well as longterm management of the RLS.

I will post some fun sleep topics in the coming days.  Thanks, everybody!

Do Your Legs Drive You Crazy at Night?


Ever get that creepy crawly sensation in your legs when you’re in bed, that feeling that just makes you want to move or kick your legs to feel more comfortable?  If so, you’re not alone.  Millions of Americans suffer from a clinical disorder called restless leg syndrome (RLS).  It’s a very prevalent–but often underrecognized and underdiagnosed–problem in which you feel compelled to move your legs at night due to the discomfort that comes when the legs are still.  It’s a form of neurologic movement disorder, really, but it is also a sleep disorder because it’s hard to fall and stay asleep when your legs are moving and kicking all evening long.

Nothing fancy is necessary to diagnose the problem; sleep study testing is usually not needed.  Proper diagnosis requires an astute physician who listens to your problem and understands the nature of your symptoms.  There are four essential clinical criteria necessary to make the diagnosis of RLS (¹,²):

1.  An urge to move the legs, usually accompanied or caused by uncomfortable and/or unpleasant sensations in the legs.  Sometimes the urge to move is present without much preceding discomfort and sometimes the arms or other body parts are involved in addition to the legs.

2.  The urge to move or unpleasant sensations begin or worsen during periods of rest or physical inactivity such as lying down or sitting.

3.  The urge to move or unpleasant sensations are partially or completely relieved by movement, such as kicking, walking or stretching, at least as long as the activity continues.

4.  The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night; in other words, there is a diurnal nature to the symptoms.  When symptoms are severe, the worsening at night may not be noticeable but have been present earlier in the day.

RLS is more common in women than in men.  There can be a family history of RLS; many RLS sufferers have family members with similar or identical symptoms.  If there are family members that also have RLS, the age of onset for RLS for an individual is generally earlier than for those without a family history of RLS.  For most people the age of onset is generally in the 40’s to 50’s, and generally the prevalence and the severity of RLS tend to increase with advancing age.

Though often RLS is “primary,” in other words, not clearly caused by another medical problem, there are some clinical entities that can be associated with RLS.  The most common of these is iron deficiency.  Pregnancy and kidney disease can also be associated with RLS.  RLS can in some cases be made worse in the setting of alcohol or caffeine use.

The actual discomfort can be difficult for patients to describe; in fact, when I ask my patients how they would describe it, the most common response is, “Well, I can’t really quite explain it to you, how it feels.”  People often use “creepy-crawly” or “heeby-jeeby” to describe the sensation.  My friend Brad Vaughn, a preeminent physician sleep specialist at the University of North Carolina School of Medicine, has a humorous lecture slide that lists the dozens of descriptive terms his patients have used over the years; the ones I particularly like are “soda bubbles,” “jimmy legs,” “Elvis legs,” and “crawling bones.”

It’s important to recognize that a lot of things can look like RLS.  Vascular disease, for example, can cause leg discomfort, but this is usually localized to a specific area of the leg, and in the case of claudication, in which a leg artery is compromised, physical movements make the leg feel worse, not better.  Arthritis is localized to the joints as opposed to other parts of the legs.  Cramping refers to a sustained, painful muscular contraction (often involving the calf muscles) as opposed to voluntary, brief leg movements that arise due to RLS.  And then, finally, there are those who simply make those repetitive “nervous” movements of the leg; we’ve all seen that.  Such movements are not generated by leg discomfort, but often occur out of habit and are not physically abnormal per se.

Every time I give a public talk about sleep and ask who in the audience has these symptoms, it’s always surprising how many hands shoot straight up. Often this problem does not come to the attention of the doctor because people “learn to live” with it through the years, even though their leg movements are driving their spouses or bed partners crazy. You wouldn’t believe what some people go through, living with this disorder. In severe cases, lifestyles completely change. RLS tends to occur in the setting of “imposed rest.” So imagine trying to sit through a movie while your legs are moving the whole time. Or being stuck in the middle seat on a plane. Or having a formal dinner or other important evening occasion. The RLS can make you miserable in such settings.

RLS is imminently treatable if you inform your doctor of what is happening to you at night. Many times patients come to see me for some other matter pertaining to sleep, and the presence of RLS turns out to be an incidental finding, or sometimes even the underlying root cause for the primary problem. People have visited me for severe insomnia, for example, and the underlying RLS, never before mentioned to anybody, turned out to be the cause.

I’ll save discussion regarding workup and treatment for another entry.  The bottom line for this post, however:  if you have the symptoms consistent with the four RLS criteria above, do yourself a favor and inform your doctor.  Treatments can really be a lifechanger.

¹.  Allen RP et al.  Sleep Med.  2003;4(2):101-119

².  Garcia-Borreguero D et al.  Sleep Med. Rev. 2006;10(3)153-167