Here’s hoping you’ve recovered from Thursdays’ turkey debauchery!
November is National Diabetes Month, and as we wrap up the month I want to bring to your attention an article recently published in the Huffington Post regarding diabetes and obstructive sleep apnea. Recent published literature demonstrates that up to 7 out of 10 diabetic people have sleep apnea. Those are astounding numbers considering how many people are diabetic in the United States.
Rather than repeat the contents of the article (written by my academy’s president, Tim Morgenthaler), I’m providing the link to it here:
There are many reasons to be concerned about this connection. First, obstructive sleep apnea is still a very under-recognized, under-diagnosed problem. Epidemiologic studies show that out of the millions of Americans with sleep apnea, only about 15% have been diagnosed! Second, there is increasing evidence that sleep apnea affects metabolism and weight more deeply and in more ways than originally thought. Finally, both sleep apnea and diabetes are risk factors for the development of heart disease, such as heart failure, early heart attack, atherosclerotic disease, and rhythm abnormalities.
Diagnosing and treating sleep apnea early have the potential of making the sleep apnea patient feel MUCH BETTER and more awake and alert during the day, but among the fringe benefits are that the SNORING STOPS and hopefully there may be a REDUCTION IN RISK for cardiac disease. I can’t underscore enough how important it is to seek medical help if you’re chronically sleepy during the day, snoring substantially at night, and having breathing pauses or choking or gasping events during your sleep.
Some of my readers may know that I’m back in school, which is why I’ve not been writing as much recently. However, winter break will soon be here, and I will write more on the topic of sleep deprivation in the near future. I wish you and yours’ a most peaceful (and snore-free) holiday season!
I must have struck a chord with yesterday’s post on dry mouth, given the responses I’ve received. Dry mouth is a very common symptom associated with sleep. So let’s continue this topic, but with a little twist. Do you awaken with your mouth feeling dry during a night of CPAP use?
As mentioned briefly yesterday, obstructive sleep apnea (OSA) is a sleep disorder of breathing associated with episodic collapse of your upper airway while you are sleeping; sleep disruption, gasping sensations at night, witnessed breathing pauses during sleep, substantial snoring, and daytime sleepiness are common clinical features of this very prevalent but under-recognized medical illness. CPAP (continuous positive airway pressure) is a primary form of treatment for OSA. CPAP is an electronic device which pressurizes room air and gently sends it down the throat via a mask to keep the airway open all night. If properly used, CPAP stops the snoring and breathing pauses, deepens your sleep dramatically, and therefore makes you feel much better and more awake and alert during the day.
Some still think of CPAP use as a primitive, invasive, or unavoidably uncomfortable medical therapy based on what they’ve seen or heard a decade or more ago; this is unfortunate, in part because many people end up foregoing medical evaluation and treatment for their sleep apnea for many years based on an erroneous perception of what their treatment may be like. There are now dozens of mask interfaces available, each with different sizes; the CPAP devices themselves are much smaller and quieter than they used to be, with lots of bells and whistles to make them more comfortable and easier to use. If used properly and if you are willing to use it, CPAP can be an absolute game-changer; untreated sleep apnea can wreck your life, and proper treatment can dramatically turn things around.
Having said that, though, there are lots of potential ways for CPAP use to go wrong, causing people to have difficulties using it or to stop using it altogether. I will write about these problems more in later posts, but one problem some CPAP users may have is dry mouth. The majority of CPAP users don’t have substantial problems with this, but if this is relevant to you or someone you know, read on.
Presuming that your dry mouth isn’t caused by one of the problems I wrote about in yesterday’s post, and if the dry mouth started or became much worse after having started CPAP, most likely this symptom is caused by oral leak or oral breathing. Your jaw muscles naturally tend to relax when you fall asleep. In some cases, the lower jaw (mandible) may then drop slightly due to gravitational forces. If you are using a nasal mask (i.e., a mask that covers your nose but NOT your mouth) or nasal pillows (i.e., soft prongs which are placed gently at the entrance of your nostrils), and if the mouth opens a little, then air from the CPAP device may then divert and escape out of your mouth. This is obviously a problem. The air dries your saliva, first of all, causing you to awaken more from sleep with that uncomfortable, parched, “Sahara desert” feeling in your mouth. Just as importantly, though, if air is leaking out of your mouth and escaping into the open space instead of going down your throat the way it should be, then you aren’t being adequately treated because your airway may again be predisposed to collapse due to insufficient air pressure. So due to sleep disruption and inadequate treatment, oral leak can lead to a perception that CPAP doesn’t work because you may still feel sleepy during the day despite CPAP use.
Oral leak is a very fixable problem. Don’t turn your CPAP device into a very expensive doorstop because of it. Before reading how to repair oral leak below, though, make sure you’ve determined where the dryness is; this is particularly important because people often don’t actually feel the air coming out of their mouths, because the leak happens while they’re asleep (when you awaken your muscles abruptly regain their tone and the mouth usually closes). If the sensation of uncomfortable dryness is in the nasal passages and/or the back of the throat, but NOT in the mouth, oral leak is probably NOT the problem; I would suggest increasing the heated humidity in your CPAP device if this is the case. However, if the dryness is clearly localized to the mouth chamber–with a pasty sensation in the mouth, for example, a feeling of having to “peel” your tongue from the roof of your mouth, dryness of the lips and teeth–oral leak is then likely the cause.
1. If you’re using a nasal mask or nasal pillows and you like your current setup, a chinstrap is usually effective. When wrapped gently around the head, it mechanically keeps your mouth gently closed. It does not need to placed tightly; it should be just secure enough to be effective, but not so tight it’s uncomfortable. People usually become accustomed to chinstrap use pretty quickly. Many straps are made of thin neoprene. However, particularly for my patients who are more heavyset or who have larger neck circumferences, I prefer a “deluxe” or “heavy-duty” chinstrap, which is wider and made of less stretchy material and therefore more likely to be effective. An added bonus: in some cases chinstrap use can be temporary; over time you may find that tendency toward oral leak has stopped after having discontinued the use of the strap.
2. Another way of addressing oral leak is with the use of a full face mask, which covers both the nose and the mouth. There are now many different full face masks available on the market. Potential issues with full face masks, however: since they’re larger masks, they may be more prone to leak than smaller masks; also, they don’t keep the mouth from opening, so you can still have some dry mouth if air continues to go in and out of your mouth (though usually substantially better). Try increasing the heated humidity (which usually comes standard) in your CPAP device should this be the case. But if you’re already using a nasal mask or nasal pillows and you’re comfortable with your current setup, a chinstrap usually does the trick with relative ease.
3. Finally, as mentioned in yesterday’s post, addressing problems causing decreased airflow through the nose (such as seasonal allergies, hay fever, sinusitis, or anatomic nasal disorders) may well reduce the tendency to open the mouth during sleep. Consider a visit to your primary care physician or an ear, nose, and throat doctor should you have symptoms that suggest such problems.
Many of us have experienced this problem at one point or another during our lives: awakening with that nasty sensation of uncomfortable dryness in the morning. Your saliva–or what’s left of it–feels like paste; there’s that funky, faintly cheesy taste in your mouth that you’re sure doesn’t smell good either.
Dry mouth, or xerostomia, can be a particular problem at night. Saliva is necessary to protect and lubricate the structures of the mouth and throat, as well as their fragile mucosal linings, from friction, foreign particles (food), and virulent organisms (viruses and bateria). While sleeping, your salivary glands naturally and normally slow down production of this saliva, and so in some respects it may be natural to awaken feeling like your mouth is a little dry. In some, however, dry mouth at night or in the early morning can be a substantial problem and a source of genuine discomfort; the words “Sahara desert” and “bone dry” are often used by my patients, for example, to describe this unpleasant sensation.
There are a number of potential causes for substantial dry mouth. Aging into your 70’s and 80’s, for example, often further slows down saliva production. Dehydration and metabolic imbalances may cause dry mouth as well. Certain medical disorders, such as Sjögren’s Syndrome and lupus, often are associated with dry mouth, as are a variety of different medications, such as antihistamines, certain blood pressure lowering drugs, diuretics (“water pills”), and anti-depressants.
Another important thing to think about is whether your mouth is open while you are sleeping. For many open-mouth breathers, the lower jaw (mandible) may naturally fall a little due to a combination of gravitational effects and jaw muscle slackening while asleep; some may be predisposed to this tendency more than others, and other factors–like body weight, neck circumference, and body position(s) of sleep–may influence mouth opening during sleep as well. However, it’s important to know if there are other problems that may cause chronic mouth opening during sleep as well, in particular things that can cause nasal congestion or other decreases in airflow through the nasal passages–such as chronic allergies, a substantially deviated nasal septum, and sinus infections. It stands to reason that if you can’t breathe properly through your nose, your mouth may be more likely to open during sleep to maintain proper airflow.
Another problem is that obstructive sleep apnea (a breathing disorder in which the airway collapses during sleep) is commonly associated with open-mouth breathing and, hence, mouth dryness and throat and oral irritation at night or in the morning. People with sleep apnea often snore loudly. Now keep in mind that you can snore with your mouth or closed (try simulating snoring with your mouth open and then with your mouth closed; you’ll see what I mean), but the snoring is generally louder with your mouth open. As a result, sleep apnea can be more noticeable to a bed partner, because the snoring is more bothersome and the loudness of the snoring provides a greater sound contrast when you sound like you stop your breathing during sleep (which is what the sleep apnea does, due to blockage of the upper airway). So as a clinician, I actually look at the open-mouth breathing as, in a paradoxical way, a good thing: it makes the sleep apnea more bothersome to both the patient and the bed partner, thus making it more likely to be brought to the attention of a physician (studies demonstrate that in the United States, about 85% of sleep apnea cases are still not yet diagnosed!).
So here are my first take-home points of 2014! I recommend that you consider these possibilities if you frequently awaken with xerostomia. Bring symptoms consistent with reduced airflow through your nose to the attention of your doctor when you speak with him/her about the dry mouth. If your oral symptoms are accompanied by a history of substantial snoring, and certainly is someone is telling you that you sound like you’re also stopping your breathing during your sleep, I strongly urge you to discuss these important issues with your doctor and consider an evaluation by a person like me, a physician who specializes in sleep medicine.
I hope your holiday season has been great so far! And it’s not over yet!
I recognize I’m posting this video late–it aired originally during the Thanksgiving holiday–but it’s worth posting now anyway; we’re still in holiday mode, after all, aren’t we?, and lots of people eat turkey at Christmas time! Jimmy Fallon, Rashida Jones, and Carrie Underwood gave a hilarious musical performance about Thanksgiving traditions on Late Night With Jimmy Fallon.
Please pay particular attention to what Rashida sings 1:29 into the clip. She parodies Katy Perry’s song “Roar,” singing, “you’re gonna hear me SNORE!”
Drowsing and falling asleep in front of the television or fireplace after a big ol’ hyper-caloric meal are so common, they seem like natural components to our American holiday tradition. The degree to which L-tryptophan in the turkey triggers an after-dinner snooze is questionable, actually. However, there are so many reasons for sleep to take you over after a huge holiday meal: sleep deprivation due to wrapping things up at work; family and friends coming into town; irregular work and sleep schedules; parties keeping you up late; alcohol, particularly when combined with certain medications; underlying medical problems; and undiagnosed sleep disorders. Untreated sleep apnea, for example, may leave you both sleeping and snoring like a bear in your recliner, disturbing your house guests.
It’s always easier to say than to do, but keeping your sleep schedules as regular as possible and getting proper amounts of sleep during the holidays may well improve your levels of wakefulness and alertness during this time of year and may bring forth even more holiday cheer! Have a great holiday week, everyone!
I play alto saxophone and percussion for Show Brazil! here in Seattle. Originally from Salvador in the northeastern Brazilian state of Bahia, the band’s leader, Eduardo Mendonça, is an internationally renowned and award-winning recording and touring artist, accomplished songwriter, teacher, community leader and benefactor to the Puget Sound area Brazilian community. His music is played and appreciated worldwide. He has played for the Dalai Lama, Pope John Paul II, and Nelson Mandela, as well as audiences all around the world. I’m honored that Eduardo christened me with my Brazilian name, Maracujá, about which I will write in an upcoming entry.
One of Eduardo’s many great songs is “Vingança,” a live version of which is shown here (from a Carnaval gig we played in 2011).
“Vingança” features both Portuguese and English lyrics. Here are the English lyrics, which served the basis for a casual over-coffee discussion I recently had with Eduardo pertaining to sleep and snoring.
She left me just because I snore
It is so bad, I sing when I dream
To me it is nothing, it is nothing to me
Boy, I am crazy, please come back to me
Always back, come back to me
Baby, it is hard, come back to me
Yeah, I made my revenge
I scratched up all her pans
She got that stuff from my mother-in-law
Yeah, it was really nice
I broke her porcelain
It is my revenge because she’s gone away
I am so bad
So, here is my interview with my friend Eduardo, who I asked to provide the song’s backstory.
EM: The wife’s left this guy and he’s really mad. He reacts with non-violence. He wouldn’t hit this woman or anything, but he’s mad, and he starts to destroy the things that she likes, like the porcelain given by her mother-in-law, and he feels really compelled to do this. It’s funny; it’s humor. It’s nothing like asking anyone to be violent to solve the problem. I didn’t compose the Portuguese and English together.
MC: So you wrote the Portuguese portion first and later you added the English?
EM: Right, many years later. After I moved to the United States, I was willing to have Americans understand a little bit more about what I was saying. I was reflecting about how snoring and sleeping problems really can damage any marriage, right? Any relationship. Snoring is in my family. My mother always complained a lot about how much my father was snoring and sometimes talking in the night, and they stayed married for many years until she passed away. She was a hero to keep living with this problem. They slept in the same room and everything, but she complained, I remember she complained. Later I found out I snore as well, though not all the time.
MC: Your wife complains about your snoring?
EM: When I’m really tired, she starts to complain about the snoring, and she reports it to me, like my mother complained, and I saw that it can cause a problem in the relationship. You sleep when you sleep. You don’t have a clue that you’re interfering with somebody else’s sleep!
MC: It’s no fault of your own, but it’s causing distress to your spouse.
EM: That’s where “Vingança” came from. From my family’s experience, from my experience, and just to alert people: who has the problem? When I wrote this song, “to me it’s nothing, it’s nothing to me.” Of course not, right? Because you don’t know that you’re causing somebody else’s problem. And that’s the humorous part: when you say it’s not a problem, but it is a problem for somebody else. That’s what’s the music is about: just to make people aware that it’s something that needs to be reviewed, something that needs to be treated and talked about, because it does interfere in any kind of relationship.
MC: So he acknowledges that he is doing something that his wife is not liking, and that is a component in what eventually ends up being a dysfunctional relationship that gets worse and worse.
EM: Yes. She left because of that, right?
MC: But did she really leave only because of the snoring?
EM: Only because of the snoring! [we both laugh]
MC: Now, I will tell you that I have had patients that have gotten divorced in large part because of the snoring.
EM: I can believe that.
MC: And it’s not really because of the loudness and the obnoxiousness of the snoring, but because the person doing the snoring didn’t believe it, or didn’t do anything about it. It’s like, “I don’t care that you’re bothered by it; I don’t care.” So I’ve actually had patients that have been in that situation, when they refuse to do anything about it, knowing that it’s bothering the spouse, and then they get divorced. That’s happened!
EM: Yep, that’s my song.
MC: So what that song is then is basically a communication to people that you shouldn’t be ignoring those things, problems that you may not necessarily help, but don’t ignore it, or else your spouse isn’t going to be happy. And it’s humorous on one hand, but on the other hand, it’s deadly serious.
EM: Yes, it’s serious. The song treats a serious problem in a light way, because sometimes we can address some problem–and can make people reflect–not in a drastic way, but with humor. It’s a way to reflect on some cause, that the action that makes that cause can be changed, can be treated, and can be rethought.
MC: You can do something about it.
EM: Right. And this guy didn’t do anything about it.
MC: And he paid a price, because she left.
Obrigado to my old friend Eduardo for bringing some awareness to sleep problems such as snoring! His music may be found on Amazon, iTunes, and Spotify; Show Brazil! is constantly touring, throughout the Pacific Northwest and beyond. I highly encourage you to explore Eduardo Mendonça’s wonderful songs.
Attention deficit hyperactivity disorder (ADHD) has again made top news in the past couple days. The federal Centers for Disease Control and Prevention recently released data demonstrating that 11% of U.S. school-age children have received a diagnosis of ADHD, and that almost 1 out of 5 boys in the U.S. have been diagnosed with ADHD. 6.4 million children 4-17 years of age have been diagnosed in this country, making for a 53% increase over the past decade. Millions of prescriptions have been written for these children, often, paradoxically, stimulants such as methylphenidate and amphetamine derivatives.
These are stunning figures, no doubt, sparking a renewal of debate regarding potential causes and solutions. Fingers have been pointed at the pharmaceutical industry, doctors, parents, schools, and our burgeoning quick-fix technology, with iPhones and video games cluttering the landscape of our–and our children’s–lives. However, there is a medical disorder–a sleep disorder–whose symptoms can be very similar to those of ADHD. This sleep problem is very real, and one that is very often overlooked.
Obstructive sleep apnea (OSA) is much more common in children than many may realize. The stereotypical sleep apnea patient is older, male, and overweight, and a misconception that may result from this stereotype is that young children, particularly skinny ones, are not prone to developing OSA. Not only is OSA quite prevalent in children, it is also easy to miss, in part because the daytime symptoms from OSA can be different in children as compared to adults.
For adults, the most common daytime symptom is excessive daytime sleepiness: drowsiness, a tendency to struggle to stay awake or to fall asleep at inopportune times, no matter how much sleep is obtained at night. Children are different. For many kids, the primary daytime manifestations of OSA are distractibility and irritability, potentially leading to poor school performance, problems concentrating, an inability to stay on task for long periods of time, and chronic conflicts at home or at school. Sound familiar? Patients diagnosed with ADHD also have such symptoms. Additional symptoms attributable to pediatric sleep apnea would include bedwetting, sleep-talking, sleep-walking, frequent sleep disruption, headaches, profuse night sweats, learning problems, depression, and retarded growth.
A big clue to possible OSA is snoring. The snoring of a young child, particularly 8 years of age and younger, really should be brought to the attention of the child’s pediatrician. A child’s or teenager’s loud snoring should most definitely be discussed with the doctor. And certainly if there are witnessed breathing pauses or gasping noises, the child’s doctor needs to be alerted as soon as possible.
Tonsillectomy and adenoidectomy represent the most common form of treatment for pediatric sleep apnea. For many children, the removal of tonsils completely solves the problem, and it’s amazing how much the child’s (and family’s) life can change for the better as a result.
So today’s pearl, reflecting these recent news from the CDC: sleep apnea is one of the most under-recognized and under-diagnosed medical disorders for children, and can present clinically in a way that is very similar to ADHD. If your child is snoring at night and distractible or irritable during the day, I would recommend a sleep evaluation.
Millions of Americans snore substantially. The ubiquity of snoring is pervasive in our culture; TV and radio shows depict people snoring for a laugh, or simply to demonstrate they are sleeping. For many, there is a simple one-to-one relationship between snoring and sleeping, such that it seems like you’re supposed to snore when you’re asleep. It’s almost like it’s an inevitable part of the human condition.
Well, the problem is that snoring is not necessarily “normal.” On the most fundamental level, snoring is just the noise resulting from vibration of soft tissues in your throat while you breathe during sleep. However, there is the potential for health effects with longstanding log-sawing. Nonetheless, it’s very common for people to blow off concerns for their snoring. Some potential reasons:
1. It’s so common. Millions of people in the U.S. are obese too, but that fact doesn’t make obesity normal, either.
2. You’re not awake to hear the snoring. By definition you don’t snore unless you’re sleeping, and you’re unaware of what is happening while you are asleep, so frequently people don’t think they snore, even when their spouses or bed partners complain bitterly about their nightly snoring noises.
Through the years I’ve heard all sorts of comments from incredulous loud snorers dragged into my clinic by angry spouses (usually wives, but husbands too). Some examples, often resulting in a dirty look or a punch in the arm by the spouse:
“Well, SHE snores loudly too!”
“She has a tendency to exaggerate things.”
“I don’t have that.”
“It’s really not a problem. She’s just making it a problem.”
“I’m telling you, I don’t snore. I don’t remember ever snoring.”
“Nobody has ever told me I snore except for HER.”
One time a man came to see me with his wife, who pulled out her iPhone and played back some audio of his intolerable snoring, only for him to reply, in all seriousness, “That wasn’t really me.”
On another occasion, a gentleman visited me in my clinic and told me when first sat down to talk, “I’m here as a birthday present for my wife.”
There are some very real reasons to take snoring seriously:
1. Marital and relationship discord. I’ve had patients actually get divorced in part because of the snoring, not necessarily because of the noise itself, but because of the spouse’s frustration in not being believed or taken seriously. That’s extreme, of course, but think about the millions of bed partners whose sleep is constantly disrupted by loud, open-mouthed snoring in close proximity. It would be maddening, right? Many have to sleep elsewhere in the house or time their bed schedules just right to minimize prolonged awakenings. Slowly, insidiously, this problem can wreck a whole family’s quality of life.
2. Loud snoring is often associated with obstructive sleep apnea. Sleep apnea is a breathing disorder in sleep, in which one’s upper airway actually collapses or closes episodically during sleep. This is a medically dangerous problem, associated with an increased risk for heart disease, early stroke and heart attack, hypertension, and sudden cardiac death. Though you don’t need to snore loudly to have sleep apnea and you don’t have sleep apnea just because you snore loudly, often sleep apnea and loud snoring can go hand in hand, and the snoring can be a tipoff for your doctor to a problem with your breathing.
3. Snoring itself may be associated with medical problems. This is the subject of intense research at the moment, but there are suggestions now in the medical literature that snoring may be an independent risk factor for metabolic diseases and cardiac problems.
How can you tell if your snoring is loud? Loudness is a relative term; I’ve had patients who delayed medical evaluation for years, for example, despite very substantial snoring, because the spouse is hard of hearing and unaware of the snoring and breathing pauses during sleep. Some general benchmarks that suggest loud snoring:
1. If it can be heard in other rooms, or other floors, of the house. I’ve had patients whose neighbors next door or ACROSS THE STREET (no joke) called them to complain of their snoring.
2. If it regularly awakens the bed partner from a sound sleep.
3. If it is louder than an ordinary, casual conversational voice.
Bottom line from tonight’s post: loud snoring is not normal just because many people snore loudly. My recommendation is that loud snoring be reported to one’s primary care physician. In future posts I’ll discuss what to do to help the “heroic” snorer. If a loved one is having clearly witnessed breathing pauses during sleep, I strongly recommend that the snorer see someone like me, a physician sleep specialist, for the consideration of breathing problems during sleep.
Dr. Morris' Sleep Help Desk 