Do You Wake Up Tired?

Sleep is important

We sleep (eventually) even when we try to stay awake, and even if we don’t entirely understand why. We do it even though it’s pretty time consuming, and we do it even when it doesn’t always do for us what it’s supposed to do (though what sleep is supposed to do for us is, weirdly enough, still up for debate).

LEARN MORE: Exploring phylogeny to find the function of sleep

LEARN MORE: Noggins in Nod: The Science of Sleep

LEARN MORE: Why Is Sleep Important?

What is sleep apnea?

Do you know anyone who snores?

Snoring is both a loud and obvious clue (for people who sleep within earshot) and a challenge to one’s social life, especially to maintaining relationships with people who might sleep nearby, for whom your snoring might be noise pollution contributing to their own disturbances in sleep.

However, snoring is very prevalent, and doesn’t always point to sleep apnea. You can be someone who snores and doesn’t have sleep apnea, and you can be someone who has sleep apnea and doesn’t snore.

LEARN MORE: Snoring: a source of noise pollution and sleep apnea predictor

History of sleep apnea

IMAGE SOURCE: The Nightmare by Henry Fuseli

Henry Fuseli’s painting “The Nightmare” shows us an image of a sleeping person with a non-human being perched on their torso, facing the viewer. This painting is often associated with sleep paralysis, another sleep disorder that can be caused by sleep apnea (but can also occur in isolation or with other sleep disorders). Sleep paralysis as a consequence of sleep apnea has been, understandably, linked to both bedroom avoidance behavior and bedtime anxiety.

LEARN MORE: Recurrent fearful isolated sleep paralysis – A distressing co-morbid condition of obstructive sleep apnea

LEARN MORE: Sleep Paralysis, a Medical Condition with a Diverse Cultural Interpretation

LEARN MORE: Sleep Paralysis

Do you feel “hagridden?”

From words like “bedridden” we can extrapolate its meaning, but it’s worth considering why this word has been used to describe sleep issues going back to at least 1677. The word hag points to witches, and ridden (in combination with hag) points not to the creepy piggyback rides I envisioned as a child when I first heard the term, but to the pervasiveness of the issue and the severity of its impact on someone’s life.

SOURCE: Google on “hagridden”

LEARN MORE: The Old Hag phenomenon as sleep paralysis: a biocultural interpretation

LEARN MORE: Witchcraft beliefs around the world: An exploratory analysis

Do you have sleep apnea?

You’ve eaten all the snacks, played all the games and now the movie credits are rolling, and your friend is already asleep. You’re really tired, too. You get ready for sleep (track down the remote and turn off the TV, plug in your phone, pull up the hood and pull down the sleeves to your hoodie because your friend forgot to give you a blanket) – when you notice that it’s weirdly quiet.

STOP BREATHING

You look at your friend, who’s kind of a loud sleeper (he gets in trouble at school more than anyone else in your friend group because even though you’ve all fallen asleep in class, he’s the one your teacher can hear sleeping). He looks fine, and he seems asleep (though you worried he might have woken up while you were rustling around for the remote and your phone charger).

However you notice that he does not seem to be breathing; his chest isn’t moving, and you’re not hearing him breathe even though he has a small room and you’re pretty close to each other in front of the TV, so that y’all could keep the volume low enough and not wake up his family.

GASP

Your laugh wakes your friend up, and he’s confused and kind of irritated, and asks what you’re laughing about. You tell him, and he just looks at you like you’re weird (which you’re starting to feel you are), and tells you to go to sleep and then rolls onto his side and goes back to sleep himself.

SNORT

You’re not sure, because you’re really tired (your phone says it’s 3:00AM), but you think you heard a snort, like when somebody laughs so hard they snort, only you didn’t hear any laughing. Your friend is awake, too, and you ask him if he heard something. He looks irritated but also a little scared, and says that he thinks so but he’s not sure. You both listen for a while and then go back to sleep.

When you get up in the morning, your friend seems really tired, which is weird because he went to sleep before you did.

GROAN

You might have heard people groan in their sleep. This groaning is called “catathrenia.” Catathrenia has only recently been considered in the context of academic sleep medicine, with the first PubMed mention in 2001, though historical mentions appear as early as 1688.

Your respiratory drive ensures that you keep breathing (whether you’re thinking about it or not). It depends on information about the balance of oxygen and carbon dioxide in your blood. Your brain and your lungs work together to keep your body in homeostasis so that you can keep on keeping on.

The groaning is thought to be caused by disruption of the internal respiratory drive, and can be another noisy symptom of sleep apnea. Some researchers, however, think it is a separate parasomnia of its own.

LEARN MORE: Parasomnias

LEARN MORE: ‘Nocturnal groaning’: just a sound or parasomnia?

LEARN MORE: The curious incident of groaning in the night-time

LEARN MORE: Catathrenia in severe obstructive sleep apnea: A novel entity never described before

LEARN MORE: Catathrenia (nocturnal groaning): A new type of parasomnia

LEARN MORE: To rout or snort in the sleepe: a detailed medical description of sleep disordered breathing and its consequences by Georg Grau in 1688

LEARN MORE: Continuous positive airway pressure as treatment for catathrenia (nocturnal groaning)

LEARN MORE: Catathrenia (nocturnal groaning): an abnormal respiratory pattern during sleep

LEARN MORE: Breath holding – A rapid eye movement (REM) sleep parasomnia (catathrenia or expiratory groaning)

LEARN MORE: Catathrenia: A rare parasomnia which may mimic central sleep apnea on polysomnogram

LEARN MORE: Catathrenia: Parasomnia or Uncommon Feature of Sleep Disordered Breathing?

HEAR A LOVED ONE STOP BREATHING? 

This minimizes the amount of time they go without air, and going without air causes health issues.

Clean up your efforts to sleep

You should also improve your sleep hygiene (the technical term for how you accommodate your sleep and prepare for sleep behaviorally). Avoid known causes of sleep disturbances or extra inflammation, elevate your head, and make your sleep space as cool, quiet, dark and comfortable as possible.

LEARN MORE: The Good, The Bad and the Ugly of Inflammation

LEARN MORE: Why all the buzz about inflammation — and just how bad is it?

Need a sleep study? These organizations can help!

Legacy Health Sleep Medicine

Adventist Health Sleep Care

Providence Sleep Disorders Center

Pacific Sleep Program

The Portland Clinic Sleep Center

Oregon Sleep Associates

The Oregon Clinic Sleep Medicine

OHSU Sleep Disorders

You can also ask your primary care provider for more information and/or a referral; sleep studies are more accessible than they used to be, and many people will have the option to access equipment that they can wear at night in the comfort of their own homes to assess their breathing while asleep.

Our study is recruiting right now at OHSU!

Types of sleep apnea

The most common is obstructive sleep apnea (OSA). Central sleep apnea is less prevalent than obstructive sleep apnea, but because treatments can vary, an accurate diagnosis is important. 

Obstructive Sleep Apnea is characterized by airway collapse and is often associated with higher body mass index (BMI). However, it is also very common in people with connective tissue disorders that impact collagen matrix formation due to lack of adequate structural support for the airway.

LEARN MORE: What Is Sleep Apnea?

LEARN MORE: A comprehensive review of obstructive sleep apnea

LEARN MORE: Diagnosis and management of obstructive sleep apnoea in adults

LEARN MORE: Obstructive Sleep Apnea: Women’s Perspective

LEARN MORE: Analysis of behavioral problems in children with sleep-disordered breathing and decreased REM sleep

LEARN MORE: The Extracellular Matrix of the Lateral Pharyngeal Wall in Obstructive Sleep Apnea

LEARN MORE: Central sleep apnea: misunderstood and mistreated!

Health Consequences of Untreated Sleep Apnea

IMAGE SOURCE: Richard T. Jones Hall for Basic Medical Sciences

Hypoxia due to apnea: Insufficient O2 or excess CO2

Some of the known risks involved with chronically untreated sleep apnea include an increased tendency to develop cardiovascular disease and an increased tendency to develop neurocognitive issues due to a lack of sufficiently oxygenated blood to supply the heart, circulatory system, brain and other organs.

LEARN MORE: Brain Circuitry for Arousal from Apnea

LEARN MORE: Hypoxic Burden in Obstructive Sleep Apnea: Present and Future

LEARN MORE: Hypoxia and Sleep-disordered Breathing: Friend or Foe?

LEARN MORE: The efficacy of antihypertensive drugs in chronic intermittent hypoxia conditions

LEARN MORE: Chronic intermittent hypoxia promotes glomerular hyperfiltration and potentiates hypoxia-evoked decreases in renal perfusion and PO2

Cardiovascular disease risks due to untreated sleep apnea

When this is not the case, cardiovascular disease can result. It’s important to get checked out if you have concerns about your heart health (whether or not you have sleep apnea), but it’s especially important to care for your heart if you do have sleep apnea because of the increased risk of cardiovascular disease.

LEARN MORE: Sleep Apnea and Sudden Cardiac Death

LEARN MORE: Associations between sleep apnea risk and cardiovascular disease indicators among Chinese and Korean Americans

LEARN MORE: Inflammation in sleep apnea: an update

LEARN MORE: Obstructive Sleep Apnea Phenotypes and Markers of Vascular Disease: A Review

LEARN MORE: Cardiovascular Disease in Obstructive Sleep Apnea: Putative Contributions of Mineralocorticoid Receptors

LEARN MORE: Sleep-disordered breathing and cardiovascular disease

LEARN MORE: Obstructive sleep apnea and stroke

LEARN MORE: Associations between common sleep disturbances and cardiovascular risk in patients with obstructive sleep apnea: A large-scale cross-sectional study

Neurocognitive consequences of apnea

My own CPAP machine has needed replacement supplies for a while, and finally receiving them made it miles easier to do the thinking involved in both my homework and my research. If you sometimes feel like things are more difficult cognitively after a bad night’s sleep, just imagine a lifetime of nights with only bad sleep and you’ll understand why treating sleep apnea is so important.

LEARN MORE: The relationship between inflammation and neurocognitive dysfunction in obstructive sleep apnea syndrome

LEARN MORE: Sleep, Health, and Society

LEARN MORE: Obstructive Sleep Apnea is Linked to Depression and Cognitive Impairment: Evidence and Potential Mechanisms

LEARN MORE: The Link between Obstructive Sleep Apnea and Neurocognitive Impairment: An Official American Thoracic Society Workshop Report

LEARN MORE: Neurocognitive functioning in comorbid insomnia and sleep apnea patients is better after positive airway pressure therapy, but worse after cognitive behavioral therapy for insomnia: exploratory analysis of cognitive outcomes from the Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea study

LEARN MORE: Obstructive sleep apnea and neurocognitive performance: the role of cortisol

LEARN MORE: Role of Oxidative Stress in the Neurocognitive Dysfunction of Obstructive Sleep Apnea Syndrome

LEARN MORE: Obstructive sleep apnea and neurocognitive function in a Hispanic/Latino population

LEARN MORE: Treatment of hypertension and obstructive sleep apnea counteracts cognitive decline in common neurocognitive disorders in diagnosis-related patterns

LEARN MORE: Multilayer network analysis of dynamic network reconfiguration in patients with moderate-to-severe obstructive sleep apnea and its association with neurocognitive function

LEARN MORE: The association between sedentary behavior and obstructive sleep apnea

LEARN MORE: The association between obstructive sleep apnea and neurocognitive performance–the Apnea Positive Pressure Long-term Efficacy Study (APPLES)

How do you treat sleep apnea?

CPAP (Continuous Positive Airway Pressure) machine

“CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep.”

— CPAP, from the National Institutes of Health

People don’t always wear their masks, and it can’t help if it’s not being worn. Luckily, those of us who need it the most are more likely to be sufficiently compliant to get significant benefit from wearing the mask. I was resistant at first, but once I experienced the relief of restorative sleep I was sold, and I’ll never go back.

Worries about dating and/or bed-sharing can be one of the obstacles to compliance, but fear not! Modern CPAP devices are surprisingly quiet and come in a wide variety of designs and sizes, so you can Goldilocks your way to a great fit. Getting good sleep in a sleek new piece of headgear will feel miles better than getting bad sleep without it.

I use the smallest size in my mask design, which covers both my nose and mouth, but many designs only cover the nose (if that’s more physically or psychologically comfortable for you). Only use distilled water in your CPAP’s water reservoir, as there are health risks associated with using water that is not distilled.

LEARN MORE: Effects of inspiratory muscle training in patients with obstructive sleep apnoea syndrome: a systematic review and meta-analysis

BIPAP: Alternative to CPAP

BiPAP (BiLevel Positive Airway Pressure) is an alternative treatment that looks similar to CPAP but works slightly differently. Where CPAP uses only one positive pressure (“pushing” air into the airway based on the needs of the person wearing the device), BiPAP uses two positive pressures, one of which is higher than the other. The higher pressure is similar to the positive pressure used in a CPAP device and is used on the inhale, while the lower pressure is used on the exhale. This additional respiratory support can help satisfy respiratory needs during sleep in cases where CPAP alone would not.

IMAGE SOURCE: How To Know if You Need a BiPAP Machine

LEARN MORE: CPAP and Bi-level PAP Therapy: New and Established Roles

LEARN MORE: Is bilevel PAP more effective than CPAP in treating hypercapnic obese patients with COPD and severe OSA?

Cannabis

Front, L to R: Aanu Ayeni, Nicole Bowles, Joshua Gonzalez, Meaghan Creech 
Back, L to R: Omar Ordaz Johnson, Ayeisha Haswarey, Latroy Robinson (Aug 2022)

For the past two years, I’ve conducted research on cannabis and sleep, and to be clear about the nature of the work, it has nothing to do with sleep apnea aside from the references to sleep apnea treatments I’ve encountered at conferences and in papers presented in our OHSU journal club.

LEARN MORE: Schedules of Controlled Substances: Rescheduling of Marijuana (DEA)

As of 2018, the AASM (American Academy of Sleep Medicine) offered a position statement that dronabinol (the synthetic THC that is one of the ways to study THC/cannabis in U.S. laboratories) is not approved by the FDA for treatment of obstructive sleep apnea, and that “medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA due to unreliable delivery methods and insufficient evidence of effectiveness, tolerability, and safety.”

LEARN MORE: Medical Cannabis and the Treatment of Obstructive Sleep Apnea: An American Academy of Sleep Medicine Position Statement

LEARN MORE: Medical Cannabis and AASM Position Statement: The Don’t Ask, Don’t Tell Wishing Well

Yet there is more and more interest in expanding treatment options as awareness of sleep apnea grows. Whether or not the AASM ever changes their ruling, people in need of relief from symptoms that are downstream consequences of sleep apnea will seek that relief in a variety of forms, and cannabis is increasingly accessible relative to other commonly prescribed palliative medications like opioids and anxiolytics. If I had to guess, I’d say the average sufferer would pick relief over AASM compliance; this seems like a place where science rubber meets science road. 

LEARN MORE: Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders

LEARN MORE: Clinical Management of Sleep and Sleep Disorders With Cannabis and Cannabinoids

LEARN MORE: Cannabinoid Use and Obstructive Sleep Apnea: A Retrospective Cohort Study

LEARN MORE: Medicinal cannabis improves sleep in adults with insomnia

LEARN MORE: Pharmacotherapy of Apnea by Cannabimimetic Enhancement, the PACE Clinical Trial: Effects of Dronabinol in Obstructive Sleep Apnea

LEARN MORE: The Effects of Cannabinoids on Sleep

There is evidence to suggest that the stigma and complex legality associated with the use of cannabis as a medicine sometimes impacts access to effective healthcare due to cannabis’s current status as a Schedule I controlled substance.

LEARN MORE: Perceived Stigma of Patients Undergoing Treatment with Cannabis-Based Medicinal Products

LEARN MORE: The role of stigma in cannabis use disclosure: an exploratory study

LEARN MORE: A qualitative review of cannabis stigmas at the twilight of prohibition

Some of the effects of cannabis consumption that might appeal to recreational cannabis consumers are also seen as drawbacks by medical cannabis consumers. These effects include but are not limited to the associated cognitive detriments, one of the more common of which is short-term memory loss.

LEARN MORE: The short-term and long-term effects of cannabis on cognition: recent advances in the field

LEARN MORE: Relationship Between Cannabis Use and Immediate, Delayed, and Working Memory Performance Among Older Adults

Another important consideration are the long-term health detriments that can be a downstream consequence of cannabis consumption, depending on modality of consumption; combustion remains the riskiest way to consume cannabis due to the carcinogenic effects of the tars produced when burning and inhaling any plant matter.

LEARN MORE: Cannabis and Lung Health: Does the Bad Outweigh the Good?

LEARN MORE: Smoking cannabis associated with increased risk of heart attack, stroke

LEARN MORE: Cannabis Science Interest (CSI) Group @ NIDA

I have analyzed many polysomnography (PSG) files from our sleeping test subjects, poring over recordings of their brain’s electrical activity, counting individual instances of waveforms known as sleep spindles, measuring delta power and comparing data between groups of participants and across nights. I’ve also collected data on heart rate variability, and conveyed all this information to my supervising postdoctoral scholar and my principal investigator for further analysis.

The data collected through the full monitoring system most commonly used in the Bowles Lab covers much more physiological ground, but my focus started with analysis of some of the many waveforms produced by the human brain during baseline sleep and then during sleep after consuming a small amount of dronabinol (two of three synthetic cannabis-based substances approved by the FDA).

LEARN MORE: Polysomnography

LEARN MORE: Quantitative electroencephalography measures in rapid eye movement and nonrapid eye movement sleep are associated with apnea-hypopnea index and nocturnal hypoxemia in men

LEARN MORE: Sleep Spindles: Mechanisms and Functions

LEARN MORE: Form and Function of Sleep Spindles across the Lifespan

LEARN MORE: Sleep Quality and Electroencephalogram Delta Power

LEARN MORE: Acute effect of vaporized Cannabis on sleep and electrocortical activity

LEARN MORE: Effects of Cannabinoid Agonists and Antagonists on Sleep and Breathing in Sprague-Dawley Rats

Research also suggests differences between the effects of THC (𝝙9-tetrahydrocannabinol, the primary cannabinoid in modern cannabis, though historically more balanced with cannabidiol aka CBD) for those who are new to consuming cannabis and those consuming cannabis frequently.

In cannabis-naive individuals, cannabis consumption decreases sleep latency (the amount of time it takes to fall asleep), while in those who consume cannabis frequently, it increases sleep latency (Bowles et al, 2017). Habituation (the reduction in physiological effect due to frequent repetition of stimulus) to the impacts or effects of cannabis is seen in other sleep parameters as well.

LEARN MORE: Recent legalization of cannabis use: effects on sleep, health, and workplace safety

LEARN MORE: Cannabinoid Use and Obstructive Sleep Apnea: A Retrospective Cohort Study

LEARN MORE: Molecular Pathology, Oxidative Stress, and Biomarkers in Obstructive Sleep Apnea

LEARN MORE: Pharmacotherapy of Apnea by Cannabimimetic Enhancement, the PACE Clinical Trial: Effects of Dronabinol in Obstructive Sleep Apnea

LEARN MORE: Medical Cannabis and the Treatment of Obstructive Sleep Apnea: An American Academy of Sleep Medicine Position Statement

LEARN MORE: Impact of dronabinol on quantitative electroencephalogram (qEEG) measures of sleep in obstructive sleep apnea syndrome

LEARN MORE: Is There a Place for Medicinal Cannabis in Treating Patients with Sleep Disorders? What We Know so Far

Surgery

LEARN MORE: Chronic insomnia remitting after maxillomandibular advancement for mild obstructive sleep apnea: a case series

My own health journey in the treatment of sleep apnea might eventually include maxillomandibular advancement surgery, as Dr. Avram Gold himself pointed out to me when I ran into him at a poster session at SLEEP2023. It can cost $40,000-$60,000, so unless a generous surgeon offers, it’ll have to wait until my insurance recognizes my condition as chronic or I win the PowerBall. 

Weight loss is often recommended as a first-line treatment for obstructive sleep apnea, but because obstructive sleep apnea can have more than one cause, the effectiveness of weight loss as a therapeutic intervention (and the ethics of weight loss as a recommendation given the many factors that can impact weight gain and prevent weight loss even in compliant patients) are not straightforward (Sutherland et al, 2016). Sometimes the issue is structural, though being told to lose weight is still the first-line treatment for obstructive sleep apnea- even if you aren’t overweight (I am). The assumption is that the weight of the throat is causing excess pressure on the airway, leading to collapse; in conditions such as mine, someone could be underweight and still suffer from obstructive sleep apnea due to the structural instability caused by faulty collagen matrices.

LEARN MORE: Maxillomandibular Volume Influences the Relationship between Weight Loss and Improvement in Obstructive Sleep Apnea

LEARN MORE: Is maxillomandibular advancement an effective treatment for obstructive sleep apnea?

My vascular system requires more external support than most; compression gear is helpful, but no longer sufficient to preserve the previously invisible status of my disabilities. At the beginning of Summer 2023, I became an ambulatory wheelchair user so that I could stay in school and keep working in research. It’s no wonder that people with conditions like mine frequently suffer from sleep apnea, as our airways are significantly more susceptible to collapsing than the airways of people with functional autonomic nervous systems who produce sturdy collagen matrices.

Improve your sleep!

If you find your health degrading faster than standard human aging, it makes sense to look into it; my own sleep study and subsequent sleep apnea diagnosis was prompted by cartoonish snoring- but not from me. 

When I received my rare disease diagnosis, I was told to prioritize getting more sleep, which I immediately started working towards. My spouse has always been a horrifically impressive snorer, and I have always been a ridiculously light sleeper, so as I was trying to get more sleep I was keenly aware of the obstacle to my rest that my spouse’s snoring represented. I finally got frustrated enough to search “how to stop someone from snoring,” and after some reading, I urged my spouse to get a sleep study done; sleep apnea and treatment with a CPAP immediately followed. From my perspective, the snoring had just been replaced by the noise of the CPAP (which is admittedly much much quieter), but I saw my spouse’s health and quality of life improve dramatically within weeks, with an improved mood being one of the first noticeable changes. Soon afterward, my spouse experienced improved cognition (likely due to neurological repairs executed after resolving the hypoxia characteristic of obstructive sleep apnea), and started to notice in me enough of the symptoms I had described witnessing to prompt me to get my own sleep study. It turns out that, though quieter, my sleep apnea was significantly more severe than my spouse’s; I’m just one case, but I hope my one case of quiet apnea prompts other quiet sleepers to investigate why they wake up tired with their healthcare provider of choice.

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