Nejm 2002;347:498; 1996;334:99

Cause:Obesity; genetic component since often familial (Ann IM 1995;122:174)

Pathophys:Anatomically smaller pharynx predisposes (Nejm 1986;315:1327)

Associated with alcohol use, which worsens apnea, and with hypertension in obese older males; are they cause or effect? (Ann IM 1985;103:190); congestive heart failure (Ann IM 1995;122:487). 1-5% of men age >60 yr; 4% of men age 30-60; 2% of women (Nejm 1993;328:1230)

Sx:Daytime somnolence (in 80%) due to disturbed sleep; history of deep snoring and apneic episodes from roommate; but such hx is only ~65% sens/specif for sleep apnea (Ann IM 1991;115:356); and HT and/or obesity; if 2 of 3 present, sleep apnea will be documented (>5, 10+ sec apneas/h sleep) w 86% sens, 77% specif in general adult primary care population (Ann IM 1999;131:485)

Si:Hypertension (90%) (Jama 2000;283;1829; Nejm 2000;342:1378)

Cor pulmonale; car accident incidence incr × 6 (Nejm 1999;340:847, 881), ASHD and CVAs (Am J Med 2000;108:396)

r/o

• Narcolepsy (Narcolepsy)
• Restless leg syndrome (see below)
• Normal elderly sleep patterns (Nejm 1990;323:520)
• REM sleep/behavior disorder (HMS 3/06); failure to have full muscle atonia during dreams, consequently causing self or bed partner injuries, seen esp in men over age 60 yr; incr incid (>33%) and often 1st sx in Parkinson's and Lewy body dementias, and multisystem atrophy; rx w d/c of SSRIs, tricyclics, and Alzheimer meds 1st then clonazepam 0.5-1 mg
• CENTRAL SLEEP APNEA, rare, rx with protriptyline 10-25 mg po hs or other tricyclic to suppress REM sleep esp if apnea occurring during REM, or progesterone as a central stimulant, or theophylline in CHF (Nejm 1996;335:562)

Lab: Noninv:Polysomnography (sleep) studies are definitive and probably best 1st test (Ann IM 1999;130:496), positive if >5, 10+ sec apneas/h sleep; if not available, overnight O₂ sat monitoring to determine respiratory disturbance index may be helpful (ACP J Club 2005;143:21), esp w autotitrating CPAP machine (Ann IM 2007;146:157)

Rx:

Avoid sleep meds and alcohol

Weight loss, even modest (eg, 20 lb) helps

O₂ hs alone decr sleep apnea

Nasal CPAP (Ann IM 2001;134:1015, 1065) helps daytime drowsiness and function if impaired, but not if pt has no complaints even w 30+ apneic spells/h of sleep; helps sx but does not prolong life in pts w CHF (Nejm 2005;353:2025)

Mandibular/tongue advancement devices if CPAP fails

Rarely tracheostomy or uvulopalatopharyngoplasty (ACP J Club 2006;145:43), and/or maxillofacial surgery

Perhaps atrial pacing (Nejm 2002;346:404, 444)