NEW YORK—What can’t be measured can’t be quantified. We know sleep is crucial, but how can we estimate the effect of broken, shallow sleep?
The total impact must include both emotional and economic figures when you consider the facts.
Almost 20 percent of all serious car-crash injuries in the general population are associated with driver sleepiness, independent of alcohol effects.
Individuals with sleep apnea, a condition in which one stops breathing during sleep, are at twice the risk of traffic accidents as unaffected individuals.
In the year prior to diagnosis, the medical expenses of individuals with sleep apnea are found to be almost two times that of control individuals who have not been diagnosed with the condition.
Sleep-disordered breathing also heightens the rate of divorce and use of paid personal leave.
Fatigue-related productivity loss is estimated to cost companies $1,967 per year for each sleep-deprived employee.
The number of tired Americans may be in the tens of millions. Dr. Jordan Stern, founder and medical director of BlueSleep in Manhattan, estimates that sleep apnea affects a quarter of Americans, and the condition has consequences for almost everyone else, not the least of whom are bed partners who have to tolerate the loud snoring and periodic gasps associated with sleep apnea.
While not limited to overweight individuals, sleep apnea is a major issue for those with extra pounds, a demographic that now comprises about 60 percent of the American population.
All systems need oxygen to function. We spend approximately one-third of each day sleeping. Those with sleep apnea are not getting enough oxygen a third of their lives. Over time, the built-up effects of reduced oxygen contribute to a host of other conditions, making the true cost of sleep apnea a sky-high, uncountable figure.
“Sleep apnea … contributes to the most common and expensive diseases that we treat, notably high blood pressure, diabetes, cardiovascular disease like stroke and heart attack—those are the common ones,” Dr. Stern said.
Women with sleep apnea are also known to have low birth-weight babies and higher frequency of cesarean section.
“Many doctors out there who treat these disorders—primary care doctors, cardiologists—are unaware that sleep apnea may be impacting the disease they are trying to control,” Dr. Stern said.
Dr. Stern is an ear, nose, and throat surgeon, and one of the few otolaryngologists in the country also board-certified in sleep medicine. Since 2008, he has run BlueSleep, a center dedicated to the diagnosis and treatment of sleep apnea.
Part of the reason many specialists may not be seeing the links between sleep and their area of medicine is that the formal study of sleep apnea started only 30 or 40 years ago.
“In the world of medicine, that is extremely, extremely young,” Dr. Stern said.
Around 80 to 90 percent of obstructive sleep apnea cases remain undiagnosed and untreated, which compounds the costs of health care, both to the individual and to the health care system, according to a report published by the National Center for Biotechnology Information.
Though sleep researchers are nowhere close to understanding all of what happens when we shut our eyes at night, we do know the following.
Adults who sleep poorly have higher incidence of anxiety, depression, and headaches, particularly morning ones. In children, sleep apnea is linked with ADHD.
Because memories are built during REM sleep, disruptions to REM can lead to poor information retention, as well as poor focus in people of all ages.
Inadequate or disrupted sleep is associated with higher cancer risk and a host of cardiovascular issues such as high blood pressure, heart palpitations, and stroke.
Sleep is also essential to our largest organ—our skin. Poor sleep begets dark circles under the eyes, and crepey, older-looking skin. The skin condition psoriasis is often exacerbated by stress and poor sleep.
Mechanics of Breathing
The good news is that sleep apnea is largely a mechanical problem—not some tricky-to-fix chemical imbalance.
Stern explains that the tongue is made of muscle interspersed with fat. One-third of the tongue actually resides in the throat. Add tonsils to the mix, and it can make for a very crowded airway.
When people gain weight, they gain it on their tongues as well as in their necks, and that bulk constricts airways. This is a major reason why sleep apnea is associated with weight.
However, the condition can affect thin people too. Some people have slender jaws and large tongues, so when they lie down, airways can be harder to keep open.
BlueSleep provides a home testing kit to easily find out if a patient has sleep apnea. The palm-size device is connected to a strap that goes around the chest, a cannula, and a fingertip oximeter. From these three points, the device records breathing effort, airflow, and oxygen level, respectively.
The collected data is analyzed and scored by BlueSleep technologist Mike Henning. He looks for how frequently the patient stops breathing, for how long, and other parameters.
At-home sleep testing significantly reduces the cost and discomfort of going to a sleep lab, not to mention that a familiar sleeping environment is more likely to yield more accurate results.
Sleep apnea is actually really simple to fix in many cases, and there are a variety of options.
For roughly 30 years, the default treatment has been Continuous Positive Airway Pressure (CPAP). Modern CPAP machines look like a cassette player-like device that pushes filtered, humidified air into the airways via a face mask.
The mask must be worn while sleeping, and though newer models have smaller, more comfortable masks, CPAP machines understandably have the lowest compliance rate of all sleep apnea treatments. Patients might get up in the middle of the night and forget to put the mask back on or just tire of the contraption and eventually stop using it.
CPAP doesn’t work for everyone either. Those who move around a lot during sleep might have trouble keeping the mask on. Those who are sensitive to noise may find the whirring of a CPAP machine annoying. And the machines require supplies such as tubing, filters, and cleansers to be repurchased.
Often, CPAP might just be overkill for all but the severest sleep apnea, according to Dr. Stern.
Less-involved options are oral devices and radiofrequency ablation. Oral devices look like retainers and are worn nightly to slide the jaw forward and position the tongue out of the way. They are good for mild to moderate sleep apnea.
Radiofrequency ablation of the tongue and surrounding tissue reduces the size of potential blockages to the airway and requires no long-term input from the patient. Radiofrequency ablation uses heat to close off blood supply to a tissue, thereby reducing the size of the tissue.
The ablation sessions are quick but may take several to achieve the desired result.
Blue Sleep’s director of operations Martin Berman has a folder bulging with complaints he’s filing regarding the insurance appeals he has to routinely submit so that the practice can get approval from insurance carriers to start testing and treating patients. Berman helps patients navigate the maze and craze of health insurance and managed care and assists patients in reviewing their insurance benefits for sleep apnea treatments. What he’s found time and again is that the insurance companies do not always agree with the doctor’s orders when treatments are more up-to-date than insurance policies might dictate.
At-home sleep testing device have been available to patients for about 12 years, and now most insurance companies, following the lead of Medicare, cover the cost of home testing.
However, some sleep apnea treatments that are approved by a patient’s insurance carrier on paper have no reimbursement amount attached them, which can make for a messy experience for both doctor and patient.
“The approval process delays patient care,” Berman said.
Often, when a patient is recommended for radiofrequency ablation treatment, the insurance company gives the go ahead and the doctor does the first part of the procedure, according to Berman. Then insurance refuses to pay because suddenly they deem the “treatment as not appropriate” even though “they’ve already given us a green light to treat.”
The insurance company might then suggest CPAP, the traditional option, sometimes even though the patient has already tried that and failed with it, or even if it’s not the doctor’s first recommendation. So some patients make a show of trying CPAP anyway.
Then the doctor’s office will appeal by filing medical documentation to support their original recommendation of the most appropriate therapy for that patient, Berman said.
To avoid this kind of insurance hassle, Berman stresses that it’s important for patients to understand their deductibles and co-pay requirements to the best of their ability. And until insurance plans catch on to newer, preferred treatment methods, be mentally prepared to try multiple treatments or pay out of pocket.
As hard as it may be for researchers to quantify the value of sleep, it seems it’s harder for insurers to quantify the value of sleep apnea treatments.
Dr. Jordan Stern
65 Broadway, Suite 901
New York, NY
Specialists May Treat the Symptoms of Sleep Apnea Without Knowing the Cause
Psychiatrists: Lack of sleep contributes to anxiety and depression in adults, ADHD in children.
Neurologists: Headaches (particularly morning headaches), memory loss, poor focus, and memory (because memories are built during REM sleep)
Primary Care: Pain from fibromyalgia
Dermatologists: Bags under the eyes, older-looking skin, psoriasis triggered by stress
Ophthalmologists: Glaucoma caused by the eye not getting enough oxygen
Audiologists: Hearing loss triggered by lack of oxygen
Urologists: Erectile dysfunction, nocturia (frequent urination) associated with high blood pressure and severe sleep apnea
Gynecologists and Obstetricians: Correlation between women who snore loudly, a sign of sleep apnea, and lower birth-weight babies and higher frequency of C-section
Gastroenterologists: Acid reflux and correlation between heavy sedation for colonoscopy and cessation of breathing
Acupuncturists: Relaxation-induced interruption of breathing
Orthopedic Surgeons: Car accident injuries that occur when drivers fall asleep at the wheel
Cardiologists: High blood pressure, heart palpitations or arrhythmia, stroke, diabetes