Is Your Snoring a Sign of Sleep Apnea?

Dr. Krieger: It's important for us to think of sleep as part of our normal function, the same way that we can't survive without eating, we can't survive without drinking, we can't survive without sleeping. So it's a quiet time for our neurons to get reorganized. They might create new connections. They may just prune out old connections. They create new pathways.

Courtney: Welcome to Health Matters, your dose of the latest in health and wellness from NewYork-Presbyterian. I'm Courtney Allison.

This season on Health Matters, we're covering your health from A to Z, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at the letter S for snoring.

You may have gotten used to the sound your partner makes while they're sleeping, but how can you tell when snoring is more than just annoying? Today, we're talking with Dr. Ana Krieger, Director of the Center for Sleep Medicine at NewYork-Presbyterian and Weill Cornell Medicine. Dr. Krieger shares the symptoms of disrupted sleep and explains all the ways it can negatively impact our health, and she offers tips to help us all breathe easier and get a good night's rest. [instrumental music] Dr. Ana Krieger, thank you so much for joining us on Health Matters today.

Dr. Krieger: Thank you so much. It's my pleasure to be here.

Courtney: So I think we're all familiar with that loud sound we make when we sleep that maybe annoys our partners or roommates, but could we start with the basics? What is snoring? What's happening in the body when we snore?

Dr. Krieger: Snoring is a sound that is generated when the tissues in the back of our throat vibrate. So it is often, not always, but often a sign that the airway is getting a little too narrow, and there is too much vibration of the tissues. The tendency of the airway is at that point to close itself off, which then becomes more of a clinical problem, and that's what we call sleep apnea, when the airway fully closes off. So snoring means the airway is open. There is a lot of air going through, but there is a lot of tension and vibration in the airway.

Courtney: How do you distinguish between ordinary snoring and snoring that could be a warning sign of something else?

Dr. Krieger: It is tricky for people to determine themselves, to be honest. You really only know after you test. When people get a sleep study, let's say, which could be done at home for a respiratory monitoring for diseases like snoring and apnea, they would be given a number of respiratory events, which are basically abnormalities in breathing that are detected during the recording time. And those numbers will come out as an index based on the duration of the recording or the duration of sleep, and that index will be used to categorize if people have more than just snoring, if they have apnea.

Courtney: What is sleep apnea?

Dr. Krieger: Sleep apnea basically is a condition that is characterized by respiratory changes during sleep. There are at least a 10-second pause in breathing, so if people don't take any air, it's almost like the airway is completely obstructed, and there is no air passage for at least 10 seconds. Or if they have a significant reduction on that airflow, so you take a more shallow breath, that either drops oxygen levels or wakes you up from sleep. The mechanics of it is just that the airway loses its ability to stay open during sleep. Could be because of age or the muscles get a little too relaxed because of obesity or increase in body weight, and we have fat deposits in the airway or around the muscles that make them more easily collapsible. Could be sometimes in women the effect of menopause, that the muscles don't behave, don't have the same tone that they used to have. There are other aspects, particularly alcohol. It's something that relaxes the muscles of the airway. Same with sedating medications. Strong sedatives or painkillers could also trigger apnea as well.

Courtney: How common is sleep apnea?

Dr. Krieger: It is very common. There are millions of people with sleep apnea in the country.

Courtney: So in addition to certain kinds of snoring, what are some other signals that we might have sleep apnea?

Dr. Krieger: Sleep apnea can be a condition that people have almost no symptoms-

Courtney: Wow.

Dr. Krieger:... because it happens during sleep. So it gets masked with that irregular sleep or perhaps an awakening here and there. Sometimes when patients develop changes in the need to use the bathroom at night, or they wake up multiple times to use the bathroom, it could be related to sleep apnea because the change in the pressurization of our system, particularly in the thoracic cage, may send a signal to the heart that it's too much pressure because you're making big efforts to breathe, and that may release a hormone that produces urine. The typical symptoms are feeling tired during the day, waking up unrefreshed from sleep, or getting tired as the day goes along, kind of running out of energy, waking up with a dry mouth or dry nose. Sometimes a headache could be a sign of having apnea, and that could be related to the fragmented sleep or changes in oxygen and carbon dioxide. Change in behaviors could be a symptom of apnea during the night, meaning people that were sleep talkers as a child, and now they are talking in their sixties, fifties. Acting out dreams could be a sign of a change in REM sleep because of sleep apnea.

Courtney: So there are people walking around with sleep apnea who have no idea they have it?

Dr. Krieger: Absolutely. We don't have a standard age for screening for sleep apnea, but I personally recommend for people over age 65 to be tested. Also, patients that have any cardiovascular issue, people that have atrial fibrillation should always be evaluated for sleep apnea. There's a big association between atrial fibrillation and obstructive sleep apnea.

Courtney: So from what you've described, it sounds like sleep apnea isn't--is really not just a sleep problem. Can you say more about what happens throughout the body when sleep apnea is left untreated?

Dr. Krieger: It's important for us to think of sleep as part of our normal function, the same way that we can't survive without eating, we can't survive without drinking, we can't survive without sleeping. There's a quiet time for our neurons to get reorganized. They might create new connections. They may just prune out old connections. They create new pathways. They have this almost water bath, like a cleansing-

Courtney: Mm-hmm.

Dr. Krieger:…we call glymphatic system, that when the artery pumps in blood to the brain, as the blood is pumped in, it creates this water flow that flush out the entire system and tries to flush out toxins and misfolded proteins of any other product that needs to be cleared. Very similar to the kidneys, right? They are cleansing our system. Sleep plays one of those critical roles in terms of helping the system clear out toxins, particularly from the brain. So not only the brain is creating this cleansing phenomena, but the other organs are now quiet, meaning that your heart rate tends to slow down, your blood pressure dips and lowers during sleep. You don't produce as much urine, so your kidney function is quiet. So it helps to preserve physical and mental function as well.

Courtney: What impact can sleep apnea have on memory, concentration, or long-term cognitive health?

Dr. Krieger: Patients with sleep apnea have a potential for cognitive changes in altered brain function, and that is because there is an alteration on the mechanisms that help the brain store information, recall information because of the fragmented sleep at night. Inadequate sleep will affect our brain function. If you add on changes because of sleep apnea, you would have higher chances of developing memory gaps, slower response time. You would have more cognitive changes in consolidation of old memory as well. There is an additional factor in sleep apnea, which is the changes in oxygen level. So now the brain at night might be functioning at low levels of oxygen, and that may also affect brain function.

A lot of that we believe is recoverable once we treat apnea, but it might not be quickly noticed. So it is something that we do worry because those changes might also accelerate any underlying process. Let's say people might have a family history of neurodegenerative disease, Alzheimer's disease, Parkinson's disease. Now, if they have sleep apnea and it's untreated, it may increase the chances of that disease to manifest itself.

So we have to be very concerned about improving breathing because that will guarantee better brain function.

Courtney: When should someone reach out to a doctor?

Dr. Krieger: If the symptoms are impairing their day-to-day activities, for sure. Of course, if you're having the common issues, loud snoring, you wake up with a sore throat or a dry throat, or congested in the morning, have a lot of mucus, a headache, tired during the day, feel like your sleep was not refreshing, all of those symptoms I think should always be evaluated.

Courtney: And treatments for sleep apnea, I think we've all seen CPAP machines. How might someone treat it if we have sleep apnea?

Dr. Krieger: People that have severe apnea typically are recommended to use CPAP, uh, which stands for continuous positive airway pressure. So basically, those machines are air pressurizers that are blown into a mask. The device is very quiet and very well tolerated, but it's not for everyone. We can use CPAP for people that have mild or moderate disease as well. For mild disease, the first-line therapy is actually a dental guard we call a mandibular advancement device. It's a guard that covers your upper and your lower teeth, and they are connected in the back. So the idea will be that your lower teeth would be advanced forward a few millimeters, and by doing that, it brings the tongue forward. So when you have that appliance at night, it increases the chance of the airway staying open. Now, there are patients that, for instance, only have apnea if they lay on their back, and the airway is completely normal if they lay on your side. So another approach could be for those patients to use a positional restriction device. Sometimes they could have inflatable air pockets on a shirt that they would wear at night or a Styrofoam belt that they can wrap at night. Another interesting treatment that has been developed over the years is a hypoglossal nerve therapy. So it's basically a stimulator that is implanted on either the chin or the neck or the upper chest, and through a wire, it connects to the nerve that moves the tongue, and that's what we call the hypoglossal. So by either coordinating an input from when we breathe or just by setting the device to rhythmically throw that impulse, it will affect the tongue muscle, and the tongue may contract or may actually come out of the mouth by one or 2 millimeters, just enough to pull the tongue out of the way of the airway.

Courtney: So if someone is looking to improve their sleep, where do they start? What are some tips you share for good sleep hygiene?

Dr. Krieger: Tips for good sleep hygiene, we could focus on 5 main items for people to consider. First is what you do in the evenings, right? I think you need to have early meal, avoid alcohol or caffeine or a lot of stimulus at night. The second is then before going to bed or that hour before going to bed, make sure it's quiet, you're off electronics. Keep your bedroom environment cold, dark, and quiet.

Number 3 is to really create a schedule for your sleep. Respect your sleep. Move a call a little bit earlier or move your flight to a different time so you can respect your sleep cycle. It's very hard for us to fully catch up with the sleep we lost. The fourth aspect, which is very important, is to get up at the same time. Have light exposure. Don't linger in bed. Don't snooze. Stand up because that standing posture activates your brain and helps you with alertness during the day. And the fifth aspect will be to really stay active during the day. Sleep is not isolated from all the other physical functions, so people that are active during the day sleep better, so we need to focus on that.

Courtney: I feel like right before I go to bed, that's when my brain gets really active and reminds me of whatever I'm stressed about or what I need to do tomorrow. What's your advice to turn off our brains before bed?

Dr. Krieger: We can't unplug the brain. It's a constant chemical overturn. We have a lot of stimulating hormones and neurotransmitters and very few kind of de-stimulating hormones that are inhibitory, we call, neurotransmitters.

So we want to enhance that function, and there are ways that we can do that by either doing deep breathing and relaxation. I love that 4, 7, 8 routine. Breathe in for 4 seconds. You hold for 7. You breathe out for 8. And that increases your parasympathetic function, which is the big antidote of adrenaline. Another important way for that monkey mind to stop is if you really put aside a time during the day to go through worries. Because otherwise, as you lay in bed and close your eyes, you are showered by, "Oh, I forgot to pick up the laundry. I didn't buy the tickets. I didn't call my mom."

Courtney: [laughs]

Dr. Krieger: So if you're able to just write down a bit of your to-do list, we need to have that outflow and time to process our emotions, our worries, our concerns because we can't function as a machine.

Courtney: Dr. Krieger, thank you so much. This is all such great advice. It is always such a pleasure speaking with you. Thank you for sharing all this fascinating information about sleep with us.

Dr. Krieger: It's my great pleasure. Loved chatting with you.

Courtney: [upbeat music] Our many thanks to Dr. Ana Krieger. I'm Courtney Allison.