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Combo Of Sleep Apnea And Insomnia Linked To Depression In Men

Men with both obstructive sleep apnea and insomnia are much more likely to have depression symptoms compared to men with either sleep disorder alone, suggests a recent Australian study.

The depression symptoms also seem to be worse for men who have both apnea and insomnia compared to men with depression but without this combination of sleep problems, the authors report in the journal Respirology.

“Obstructive sleep apnea and insomnia are the two most common sleep disorders and can occur together in the same individual,” lead author Dr. Carol Lang, a researcher at the Basil Hetzel Institute at the University of Adelaide Queen Elizabeth Hospital Campus, told Reuters Health.
“We know that each of these disorders is individually associated with poor physical and mental health outcomes in patients. However, we don’t know very much about if, or how, the two disorders interact with each other and the health outcomes when they coexist in the same individual,” Lang said in an email.

A person with obstructive sleep apnea has their breathing interrupted multiple times during sleep by narrowed or blocked airways. The condition is often treated by wearing a continuous positive airway pressure, or CPAP, mask to keep the airway open.

Insomnia was defined in this study as the inability to fall or stay asleep together with feeling fatigued during the day.

Lang and her colleagues enrolled 700 mostly middle aged men in Adelaide with no diagnosis of obstructive sleep apnea. All of them underwent at-home sleep monitoring known as polysomnography and answered questions about their sleep habits, health conditions and possible depression symptoms.

cpap

Researchers found that more than half of the men had undiagnosed obstructive sleep apnea. In the entire group, 323 men had sleep apnea only, 37 had insomnia only and 47 had both conditions.

Of the men with both sleep apnea and insomnia, 43 percent also had depression, compared with 22 percent of the men who had insomnia alone and 8 percent of the men who had sleep apnea alone.

Sleep deprivation, which may occur in chronic insomnia, is known to adversely affect muscles involved in breathing and may contribute to the propensity and severity of sleep apnea, Lang noted.

“There are also many biochemical signaling pathways in the body through which sleep apnea, insomnia, and depression may interact with each other,” she said.

If one of the sleep disorders is suspected, primary care providers should consider the possibility of co-existing sleep apnea and insomnia as well as their patient’s mental health, said Lang.

“Since some hypnotic medications could potentially be counter-productive, patients should be referred to sleep clinics, and if necessary mental health clinics, for further investigation so that the most appropriate treatment strategy can be implemented for them as an individual,” she said.

Our sleep is important for our physical and mental health, Lang added, and a person who experiences sleep problems should talk to a medical practitioner to see if further investigation is necessary.

By Shereen Lehman       Tue Jun 20, 2017       Reuters Health
SOURCE: bit.ly/2tqz3bK        Respirology, online June 7, 2017        www.reuters.com
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Pacemakers Might be a New Option For Treating Sleep Apnea

Pace to breathe — New treatments for sleep apnea

Sleep apnea is a common condition. As many as 26% of all Americans may suffer from this condition, in which there are long pauses between breaths during sleep. Unfortunately, many patients with sleep apnea do not tolerate the most effective current therapy, continuous positive airway pressure, or CPAP. For some of these people, a new approach pacemaker therapy may be an alternative.

Pacemakers for sleep apnea? This must be a “typo,” right? Don’t you really mean heart pacemaker? No, this isn’t a typo. Pacemakers are some of the newest treatments for sleep apnea. Before explaining how they work, a short physiology lesson is necessary.

Normally, when you breathe in, air flows from the nose and mouth, past the back of your tongue, through the trachea and down into your lungs. This occurs because nerve signals from the brain activate the diaphragm to produce inspiration. The resulting negative pressure pulls air in. However, these nerve signals also stimulate muscles surrounding the throat, including the tongue to contract in order to prevent the airway from being suctioned closed with breathing. Sleep apnea occurs when these processes fail during sleep, and consequently air does not enter the lungs.

There are two types of sleep apnea. The most common is obstructive sleep apnea, which occurs when there is repetitive collapse of airway at the back of the throat. In obstructive apnea, the stimulus to the throat muscles is insufficient to prevent their collapse and the airway becomes blocked. Less common is central sleep apnea. In central apnea, nerve signals from the brain are absent for prolonged periods of time, and there is no effort made to breathe during these intervals.

The research around new sleep apnea treatments

In a recent study, pacing of the hypoglossal nerve in the neck during sleep was effective treatment for people with moderate to severe obstructive sleep apnea. Twelve months after pacemaker insertion, the average number of obstructed breathing events decreased by approximately 50%. In addition, nighttime oxygen levels improved, as did measures of quality of life and daytime sleepiness. There were few side effects.

How does the hypoglossal pacemaker work? The pacemaker has three major components. The first is the stimulation electrode, which is surgically implanted on one hypoglossal nerve (there are two nerves, right and left). The second is a sensing electrode, which is surgically inserted in the chest and detects when a person starts to inhale. The third is the electrical generator, which supplies battery power for the pacemaker. When the sensing electrode identifies the start of a breath, it signals the stimulation electrode to activate the hypoglossal nerve, which is the primary nerve to the tongue. This causes the tongue muscle to stiffen and resist airway closure, thus preventing apnea.

Although the hypoglossal pacemaker sounds like a dream come true for people with obstructive sleep apnea who have trouble using continuous positive airway pressure (CPAP), it has not been used in large numbers of patients to date. Two reasons have hindered widespread use––cost (about $30,000) and lack of data showing effectiveness in patients who are severely obese. This is important because two-thirds of people with obstructive sleep apnea are overweight or obese. The insertion procedure is not complicated, although it requires a brief surgical procedure and follow-up to adjust the pacemaker settings. However, as more experience with it accumulates, usage of this novel therapy may increase.

Central sleep apnea also may be amenable to pacemaker treatment. Central apnea frequently is observed in patients with heart failure, and is difficult to treat. Recent studies show that a pacemaker inserted through a central vein, in a manner similar to placement of a heart pacemaker, can stimulate the phrenic nerve, which controls contraction of the diaphragm. This pacemaker senses the absence of any effort to breathe and then activates the phrenic nerve. The phrenic nerve then causes the diaphragm to contract, initiating inspiration. The studies show that central apneas decrease and sleep quality improves. Although the pacemaker is not yet available in the United States, FDA approval may be forthcoming.

JULY 27, 2016
Stuart Quan, MD, Contributing Editor
sleep-apnea-snoring

Medical Conditions Related to Sleep Apnea

Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.
Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. Research suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Apnea itself may also cause pressure changes that trigger GERD. Obesity is common in both conditions, and more research is needed to clarify the association.
Polycystic Ovary Syndrome (PCOS). Obstructive sleep apnea and excessive daytime sleepiness appear to be associated with polycystic ovary syndrome (PCOS), a female endocrine disorder. About half of patients with PCOS also have diabetes. Obesity and diabetes are associated with both sleep apnea and PCOS and may be the common factors.

Complications

Sleep apnea can lead to a number of complications, ranging from daytime sleepiness to possible increased risk of death. Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.

Daytime Sleepiness

Daytime sleepiness is the most noticeable, and one of the most serious, complications of sleep apnea. It interferes with mental alertness and quality of life. Daytime sleepiness can also increase the risk for accident-related injuries. Several studies have suggested that people with sleep apnea have two to three times as many car accidents, and five to seven times the risk for multiple accidents. Undertreated sleep apnea is a major risk factor for injury at factory and construction work sites.

Effects of Sleep Apnea on Heart and Circulation

Sleep-disordered breathing is very common among patients with heart problems such as high blood pressure, heart failure, stroke, heart attack, and atrial fibrillation. This link may be because both cardiovascular conditions and sleep apnea share a common risk factor of obesity. However, increasing evidence suggests that severe OSA is an independent risk factor that may cause or worsen a number of heart-related conditions.
 
High Blood Pressure. Moderate-to-severe sleep apnea definitely increases the risk for high blood pressure (hypertension) even when obesity is not a factor. Doctors are not certain whether treating OSA with CPAP reduces the risk for high blood pressure, but studies indicate that CPAP may help prevent or decrease high blood pressure.
Coronary Artery Disease and Heart Attack. Sleep apnea appears to be associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. Studies suggest that patients with moderate-to-severe obstructive sleep apnea have a higher risk for heart attack.
Stroke. Sleep apnea may increase the risk of death in patients who have previously had a stroke.
Heart Failure. Up to a third of patients with heart failure also have sleep apnea. Central sleep apnea often results from heart failure. Obstructive sleep apnea can cause heart damage that worsens heart failure and increases the risk for death.
Atrial Fibrillation. Sleep apnea may be a cause of atrial fibrillation (irregular heartbeat).

Other Adverse Effects on Health

Sleep apnea is associated with a higher incidence of many medical conditions, besides heart and circulation. The links between apneas and these conditions are unclear.
  • Diabetes. Severe obstructive sleep apnea is associated with type 2 diabetes.
  • Obesity. When it comes to sleep apnea and obesity, it is not always clear which condition is responsible for the other. For example, obesity is often a risk factor and possibly a cause of sleep apnea, but it is also likely that sleep apnea increases the risk for weight gain.
  • Pulmonary hypertension (high pressure in the arteries of the lungs).
  • Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
  • Seizures, epilepsy, and other nerve disorders. There may be an association between seizures and obstructive sleep apnea, especially in older adults. Some studies have shown treatment of obstructive sleep apnea may help in the control of refractory seizures.
  • Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder may cure the headache.
  • High-risk pregnancies. Sleep apnea may increase the risk of pregnancy complications, including gestational diabetes and high blood pressure.
  • Eye disorders, including glaucoma, floppy eyelid syndrome, optic neuropathy conjunctivitis, dry eye, and various other infections and irritations. Some of these latter symptoms may be associated with CPAP treatments for sleep apnea.

Psychological Effects

Studies report an association between severe apnea and psychological problems. The risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder.

Effects on Bed Partners

Because sleep apnea so often includes noisy snoring, the condition can adversely affect the sleep quality of the bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.

Effects in Infants and Children

Failure to Thrive. Small children with undiagnosed sleep apnea may “fail to thrive,” that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system.
 
Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.
09/19/2012
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine,
Harvard Medical School; Physician, Massachusetts General Hospital. 
Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.
source: umm.edu


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Sleep Apnea Takes Toll on Brain

By Janice Wood

A new study shows that people with sleep apnea show significant changes in the levels of two important brain chemicals.

This could be the reason so many people with sleep apnea — a disorder in which a person’s breathing is frequently interrupted during sleep, as many as 30 times an hour — report problems with thinking, such as poor concentration, difficulty with memory and decision-making, depression and stress.

Researchers at the University of California Los Angeles School of Nursing looked at levels of the neurotransmitters glutamate and gamma-aminobutyric acid, known as GABA, in a brain region called the insula. This area integrates signals from higher brain regions to regulate emotion, thinking, and physical functions, such as blood pressure and perspiration.

They found that people with sleep apnea had decreased levels of GABA and unusually high levels of glutamate.

GABA is a chemical messenger that acts as an inhibitor in the brain, which can slow things down and help keep people calm. It affects mood and helps make endorphins, researchers explain.

Glutamate, by contrast, is like an accelerator. When glutamate levels are high, the brain is working in a state of stress, and consequently doesn’t function as effectively. High levels of glutamate can also be toxic to nerves and neurons, the researchers noted.

“In previous studies, we’ve seen structural changes in the brain due to sleep apnea, but in this study we actually found substantial differences in these two chemicals that influence how the brain is working,” said Dr. Paul Macey, the lead researcher on the study and an associate professor at the University of California, Los Angeles School of Nursing.

brain-chemicals

Macey said the researchers were taken aback by the differences in the GABA and glutamate levels.

“It is rare to have this size of difference in biological measures,” he said. “We expected an increase in the glutamate, because it is a chemical that causes damage in high doses and we have already seen brain damage from sleep apnea. What we were surprised to see was the drop in GABA. That made us realize that there must be a reorganization of how the brain is working.”

He added that the study’s results are actually encouraging.

“In contrast with damage, if something is working differently, we can potentially fix it,” he said.
“What comes with sleep apnea are these changes in the brain, so in addition to prescribing continuous positive airway pressure, or CPAP, physicians now know to pay attention to helping their patients who have these other symptoms,” he continued. “Stress, concentration, memory loss — these are the things people want fixed.”

A CPAP machine helps an individual sleep easier, and is considered the gold standard treatment for sleep disturbance.

In future studies, the researchers said they hope to determine whether treating sleep apnea using CPAP or other methods returns patients’ brain chemicals back to normal levels.

If not, they will turn to the question of what treatments could be more effective. The researchers said they are also studying the impacts of mindfulness exercises to see if they can reduce glutamate levels by calming the brain.

The study, conducted at the University of California, Los Angeles Sleep Disorder Center, was published in the Journal of Sleep Research.