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If you were to imagine the typical person who is at risk for Obstructive Sleep Apnea (OSA) who would come to mind?
You would be in good company if you first think of someone who is overweight, middle aged, male, and who snores like a banshee—perhaps this description even applies to your spouse, family member, or friend who has already been diagnosed with OSA(or who you suspect may have it).
This commonly held mental image of the stereotypical sleep apnea patient is based in truth—multiple scientific studies confirm that middle-aged, obese males who snore loudly are indeed among those at highest risk for this serious and potentially deadly condition. Our medical community has long focused on this type of patient as it has struggled to manage this epidemic.
A recent discussion with a primary care physician reinforced this. As we discussed that clinic’s methods of identifying those at risk for sleep apnea, this physician quipped, “Well, we don’t miss many of the fat old men!” This was an illuminating statement, as we have become aware that sleep apnea can potentially affect just about every age group, and both sexes, depending on individual circumstances.
It is now well understood that OSA is a complex, chronic condition that is influenced by MULTIPLE factors. The Mayo Clinic has stated that some of those factors are:
- Being male
- Excess weight
- Being older
- Thick neck circumference
- A narrowed airway
- Family history
- Use of alcohol, sedatives, or tranquilizers
- Smoking
- Nasal congestion
Right off you can see that the first three factors listed DO describe our stereotypical OSA patient! But this is not the whole story; so let’s tackle these risk factors individually to gain a better understanding of who is truly at risk for OSA…
Multiple studies confirm that men are two to three times as likely to suffer from sleep apnea compared to women, and this may be due to several reasons.
First, men tend to report more classic signs of OSA such as heavy snoring and excessive daytime sleepiness, whereas women more often complain of OSA-related symptoms such as insomnia, anxiety, and headaches/TMJ related pain (this may result in fewer sleep testing recommendations from family physicians for females). Second, females are generally more aware of their partner’s sleep problems, so they more frequently witness their partner’s apnea events and then perhaps encourage their male bed partners to get testing. There also appears to be an airway protecting function of the female hormone estrogen that may account for this lower prevalence among women.
This may explain why some studies show that men tend to have more severe OSA and longer apnea events than females. It may also explain why women’s risk for sleep apnea increases dramatically after menopause.
As of 2019 approximately 42% of the American adult population are considered obese, and sleep apnea is more common in obese patients compared to those of normal body size. This really makes sense if you think about it; as we get bigger on the outside—especially if fat deposits occur in the neck and in tissues surrounding the upper airway—our airway gets smaller and less able to resist collapse. As obesity rates have increased over the past few decades, so has the prevalence of sleep-disordered breathing.
Obesity is such a key factor in OSA that many people who lose significant amounts of weight may find their sleep apnea reduced from severe to a milder condition, or that their OSA is even fully resolved. Weight loss may be easier to achieve with active therapy such as CPAP or Oral Appliance Therapy due to the therapies’ positive effect on the hormones that regulate hunger. A more rapid weight loss can occur for severely obese patients that have bariatric surgery.
As we age, two things tend to happen that increase our risk for OSA: we tend to gain weight, and we tend to lose muscle tone. Loss of muscle tone can directly affect our airway because the airway now collapses more easily. In general, rates of OSA are higher for older (over age 40) versus younger adults. However, sleep apnea can affect people of ALL ages, including teens and children, although at lower rates.
A narrowed airway is the crux of the whole problem—almost all the other risk factors mentioned here relate to this! It is easy to understand that if the airway is physically smaller due to the presence of excess fat or large tonsils, even a small degree of collapsing during sleep would further compromise your airway. Dentists are occasionally asked if there is a genetic or family history component to sleep apnea, and the answer is… yes!
Your family genetics may mean you’re more likely to have smaller jaws, or to have a high palate, or are prone to obesity—all of which increases your risk for OSA. Studies now suggest very strong genetic foundations for this condition. narrowed airway is one of the most common causes of sleep apnea in children—in this instance due to large or swollen tonsils or adenoids that cause a physical narrowing of the airway as opposed to the collapsing airway more commonly seen in adults.
USE OF ALCOHOL, SEDATIVES, AND TRANQUILIZERS
These substances are often used for insomnia, but they may also affect your airway and worsen your OSA. Many people drink alcoholic beverages in the evening, sometimes with the mistaken thought that it helps them sleep better. However, research shows that alcohol doesn’t really help you sleep better but instead, creates more of a sedative effect. Alcohol may also cause you to wake up in the middle of the night as it is processed by your liver. This could be because the chemical byproducts have been shown to promote a more awake state, or because it is a diuretic which promotes awakening to urinate.
We all know that alcohol is a relaxant, and it can cause a direct relaxation of your airway muscles, thereby promoting or worsening underlying sleep apnea. It has even been suggested that some hangover symptoms are due to the increased level of sleep apnea caused by alcohol’s effects on the airway.
Because other sedatives such as Benzodiazepines (Valium, Xanax, etc.) and tranquillizers also cause muscle relaxation, they may also worsen your sleep apnea. Newer sleep aids such as Ambien and Lunesta seem to have less direct effect on the airway, but come with their own unique and challenging side effects.
SMOKING
The ill health effects of smoking are so well documented that everyone is aware of its inherent dangers, but less known are the potentially damaging effects on your sleep from tobacco use. Smoking has been shown to disrupt your normal sleep cycles and damage the function of your very important upper airway muscles. And, the inflammation smoking causes in your throat means the upper airway may be more swollen which in turns makes the overall airway smaller.
NASAL CONGESTION
Nasal congestion is common among those of us who suffer seasonally or through the year with allergies, commonly referred to as Allergic Rhinitis. Because nasal congestion can cause swelling in your upper airway, it may worsen both snoring and underlying sleep apnea. Nasal congestion can be so profound that it promotes mouth breathing, which has also been shown to worsen airway collapsibility (this could also be caused by a physical blockage in the nasal anatomy such as the deviated septum mentioned earlier). If you do suffer from chronic nasal congestion, you will likely suffer from dry mouth while sleeping which also increases risk of dental decay and gum disease.
Fortunately, solutions do exist: you can use an over-the-counter (OTC) nasal decongestant spray such as Flonase, an OTC allergy medication such as Zyrtec, or consider consulting with an Ear, Nose and Throat specialist (ENT) to determine whether a minor surgical procedure could improve your nasal breathing long-term. There are also numerous remedies for dry mouth we can help you with!
As you may now realize, there are MULTIPLE risk factors for OSA –how many of these apply to you or your loved ones?
If risk factors exist, a consultation with your primary care doctor or a sleep physician is warranted. The bottom line, however, is there are many of us who lack these common risk factors but may still suffer from sleep apnea. For example, we now know that many otherwise healthy, slender, young females without any of the above risk factors are prone to UARS (Upper Airway Resistance Syndrome), thought by some to be a milder form of OSA but that can cause many of the same symptoms as sleep apnea. While it is important to understand these common risk factors, anyone who suffers from poor sleep in general is encouraged to discuss their issues with a medical professional.