Several years back, a patient of mine in his mid 40’s asked me as he was walking in for his essential oral hygiene appointment, “Doc, I hear dentists can do something about sleep apnea. I want to hear all about it.” Prior to this I had been pretty proud of myself being up to date on most things dental. I go to at least two annual dental conferences, I am up on my continuing education courses and then some. Sleep Apnea? Never heard of it. I vowed I would never let that happen again.
OSA, or Obstructive Sleep Apnea, is a sleep disorder where, due to lack of oxygen getting to the brain, one can wake up several times an hour, several hours a night. If the brain literally gets below 90% oxygen saturation, it will get into survival mode and triggers the body to wake up in order to survive. When we sleep, our breathing is taken over for us, like on autopilot. If we can’t breathe properly, however, our brains want us to start breathing on our own again. For every apnea event, two major things happen to the body: sleep is disrupted and the oxygen concentration in the blood drops. Both effects can adversely affect the brain.
Normal sleep is not simply based on quantity, it is also based on quality. Sleep allows our bodies to rejuvenate, our brains to restore. In an interrupted sleep, this cannot happen, which can tax the brain and the heart.
One of the ways we know breathing has become obstructive in our sleep is snoring. Snoring can have causes that aren’t due to underlying disease. Examples include nasal congestion, allergies, anatomic variation of the nose (deviated septum) and soft palate, or alcohol consumption. For women, this can also include pregnancy. Loud nightly snoring, however, is a hallmark of OSA, according to the U.S. National Institutes of Health. Also characterized by brief periods where breathing stops, often followed by gasping for air, sleep apnea is becoming recognized as a contributor to serious health conditions, such as high blood pressure, heart disease, poor blood sugar metabolism and Alzheimer’s Disease.
Given what researchers know about the importance of sleep for brain health, there is concern that sleep apnea could not only worsen Alzheimer’s disease, but trigger its onset at a younger age. In one study it was recently discovered that, “Sleep apnea actually accelerated the movement into mild cognitive impairment diagnosis for individuals who had been cognitively healthy just a few years prior. The evidence for this connection is very strong,” says Said Mostafavi, M.D., the Chief Medical Officer for Advanced Sleep Medicine Services Inc., and a sleep specialist. “When you look at the numbers and the prevalence of dementia in sleep apnea patients, as compared to the general population, it is very striking.”
Standard protocol for diagnosis of OSA goes like this: screenings can be performed at both medical and dental offices. Why? People tend to go more to their dentist than to their doctor. Joyful Dental Care performs OSA Screenings along with Medical Histories annually. The Epworth Test is a series of questions that, if scoring 15 or higher, could indicate a sleep disorder. Dentists are not allowed to diagnose, but we can engage the patient with further questions, and order a sleep study. An at-home sleep study can be ordered or the study can be performed in a sleep center, either independent or at a hospital. Mine was at North Shore Hospital in Skokie. The room looks very much like a decent average hotel room. One can bring in anything to help them sleep. There is a camera above the tv in front of the bed, and about 12 leads are running from head to chest and arm to read one’s pulse, blood pressure, oxygen saturation, and breathing rate. I was able to sleep on my side, however. I had been afraid I would not be able to do so. Fortunately I did fall asleep by 11pmish and they had me up at 6amish. I had a series of questions to answer: how did I feel I slept? Was I comfortable? How many hours do you think I slept? I got my results back that Monday. Fortunately, my insurance paid for all but $25.00 of it. Some insurances will not pay for the at-home study, and some insurances will want a follow-up study if an at-home study is performed and the result is Severe Sleep Apnea. Insurance information can be obtained through a pre-estimate. Some dental offices like Joyful Dental Care has a third party that can generate this information prior to taking the study.
Currently, the “gold standard” treatment for OSA is Continuous Positive Airway Pressure. The machine increases the air pressure in the throat to prevent the airway from collapsing when inhaling. It also decreases snoring. The machine has a filter and small tank of water, which essentially works as a humidifier. There is a tube that connects the unit to a mask that is placed over the face while asleep, and a chin strap keeps it in place. Smaller, nasal tubes can be used instead. The CPAP is still the most effective nonsurgical treatment for sleep apnea, and it’s also the first solution when diagnosed with OSA. With use over time, it reduces daytime sleepiness, lowers blood pressure during the day and night, and reduces heart problems for those with heart disease.
Another way dentists are involved with OSA is taking impressions (either digital and/or with putty) and having a lab fabricate an oral appliance for those who cannot tolerate the CPAP. Protocol states that the CPAP must be have attempted to be worn for at least six months, the Sleep Study is less than two years old, and have either mild or moderate OSA. Their primary care physician/pulmonologist/sleep physician must also provide medical clearance in writing that this type of solution is necessary for their patient. The Mandibular Advancement Device (MAD) keeps the lower jaw (mandible) forward as if we are still sitting or standing up. Due to the fact that our jaw joints are basically hinges, when we lean back and are laying on our backs our jaws go back, closing the airway, preventing proper breathing. Patients that I have made an appliance for have complained of claustrophobia with the CPAP, not being able to sleep on their sides, not being able to get a good enough seal with the mask on the face, chronic dry mouth/lips/throat/nose/eyes to the point where, in the morning, they could not talk/swallow/blink. Once the appliance has been delivered, the patient must go back for a follow-up sleep study 3 weeks to 3 months after the MAD has been delivered and properly fitted. This is to make sure the appliance is keeping the airway open enough for the patient to breathe in enough air for proper oxygen to get to the brain.
If left undiagnosed, OSA can begin to cause mild impairment in attention, memory and executive function as early as middle-age. More than 18 million Americans have OSA. More than one study has shown women with sleep apnea were nearly twice as likely to develop cognitive impairment as they age.
“Cognitive Impairment”, if left undiagnosed and untreated, can turn into an irreversible disease such as dementia. There are several forms of dementia, with Alzheimer’s being the most common. More than five million Americans have Alzheimer’s Disease, making up 62% of the dementias. “Low oxygen is directly related to causing brain damage,” Mostafavi says. “And one of the most vulnerable parts of the brain to a reduction in oxygen is the hippocampus.” This is a small horseshoe-shaped structure in each hemisphere of the brain, located near the center of the brain. It’s the place where long term memories are stored and is one of the first structures affected by Alzheimer’s disease.
Sleep disruption constitutes a core component of Alzheimer’s Disease (AD), and abnormalities of sleep symptoms have been shown to emerge well before clinical onset of AD. In 2015, a New York University study found that people with sleep apnea, on average, were diagnosed with mild cognitive impairment 10 years before their peers who didn’t have the breathing disorder. The sleep apnea patients in this study also seemed to experience an accelerated timeline for Alzheimer’s disease. People with the disorder who developed Alzheimer’s disease were diagnosed five years sooner on average than the non-sleep apnea sufferers. So, people diagnosed with sleep apnea but do not do anything about it are at much higher risk for Alzheimer’s Disease due to the fact that lack of proper amounts of oxygen to the brain over time damages it. And, once symptoms start, Alzheimer’s worsens more quickly for these people vs those that do not have OSA.
This research has been proven that the average period of Alzheimer’s Disease detection from the time of OSA occurrence is 5.44 years. Male subgroup analyses reveal that the effect of OSA remains significant in patients aged ≥60 years. Patients with OSA who received treatment (continuous positive airway pressure) exhibited a significantly reduced risk of Alzheimer’s compared with those without treatment.
Degeneration of the neural pathways that regulate sleep and the cycle of sleep and wake could be responsible for sleep apnea in Alzheimer’s patients. REM sleep stage is the most powerful and the most critical in maintaining overall health. One of the proposed functions of REM sleep is the regulation of emotional reactivity and mood states, both of which have been shown to be disturbed in AD patients. Sleep apnea could contribute to neural dysregulation through low oxygen levels or through alterations to blood vessels triggered by the body’s response to sleep apnea’s disrupted sleep and plunging oxygen levels. It has been further suggested that around 50% of patients with AD will have experienced OSA at some time after their initial diagnosis, negatively impacting on its prognosis and the quality of life.
So what is Alzheimer’s Disease exactly? AD is a progressive disease, where dementia symptoms gradually worsen over a variable number of years. In the United States, someone develops AD every 66 seconds, and is the sixth leading cause of death. Currently there are about 18 million Americans who live with AD. The AD worldwide epidemic has been touted as the only disease among the top 10 causes of death in the developed world that cannot at present be prevented, cured or even slowed. One of the problems is no one case is the same. In early stages, memory loss is mild (most recent events), but with late-stage Alzheimer’s, one not only cannot remember events, they also lose all memory, including the ability in remembering how to walk and talk. On average, a person with Alzheimer’s lives four to eight years after diagnosis, but can live as long as 20 years, depending on other factors.
And, unfortunately, there are other collaborative causes that increase dementia risk. These include systemic inflammation and obesity, which are likely to interfere with immunological processes of the brain, and further promote disease progression.
How can we prevent sleep apnea? Getting a good night’s sleep (7-8 hours nightly) — and all ways to improve the quality and quantity of sleep revolve around this: lose weight if you’re overweight; maintaining an anti-inflammatory diet (little amounts of over-processed food products/high amounts of whole fruits, vegetables, proteins, fats); exercise regularly; drink alcohol moderately, if at all, and don’t drink several hours before bedtime; quit smoking; use a nasal decongestant or allergy medications; don’t sleep on your back; avoid taking sedative medications such as anti-anxiety drugs or sleeping pills. Alcohol, prescription and OTC sleeping aids can prevent the REM sleep cycle in occurring, therefore sleep quality has been compromised.
Urban myth: we can make up sleep on the weekends. NOT TRUE. Every night’s sleep is precious. Our bodies (hearts, minds, lungs, immune systems, skin, bones, glands, eyes, etc.) require time to STOP and REST uninterrupted. We are only as good as the last amount of time we slept continuously. Hope we all sleep well tonight, and every night.
Emamian F., Khazaie H., Tahmasian M., Leschziner G.D., Morrell M.J., Hsiung G.Y., Rosenzweig I., Sepehry A.A. The association between obstructive sleep apnea and Alzheimer’s disease: a meta-analysis perspective. Front. Aging Neurosci. 2016;8:78.
Association . 2016. Association A.s., 2016. 2016 ALZHEIMER’S DISEASE FACTS AND FIGURES
Mander B.A., Winer J.R., Jagust W.J., Walker M.P. Sleep: a novel mechanistic pathway, biomarker, and treatment target in the pathology of alzheimer’s disease? Trends Neurosci. 2016;39:552–566
Content provided by Women Belong member Joy Poskozim