BPA5599 - SECTION 5: ASSESSMENT AND MORE COMPLEX SLEEP PROBLEMS
Section 5: Assessment and More Complex Sleep Problems
Information that Indicates Sleep Apnea
DSM-5 Codes: G47.33 Obstructive Sleep Apnea Hypopnea
Prevalence = 3-7%
DSM-5 Codes: G47.31 Idiopathic Central Sleep Apnea
Also: R06.3 Cheyne-Stokes breathing
Central Sleep Apnea comorbid with opiod use
Can this disorder legitimately be diagnosed by a Master’s level clinician?
No. Sleep Apnea diagnoses require evidence from a polysomnogram administered under the supervision of a sleep specialist.
Sleep apnea is a disorder that occurs when sleeping is interrupted due to something interfering with breathing during sleep. The interruption to the flow of oxygen causes a person to have multiple short periods of waking up in response to the loss of oxygen, severely restricting the amount of sleep the person is able to get, and doing great harm to the flow of the normal sleep cycle.
The discovery of signs and symptoms of sleep apnea will likely be a less straightforward process than with Insomnia Disorder. The clinician will need to gather circumstantial evidence to arrive at a conclusion that sleep apnea may be present. The questions used to gather that circumstantial evidence are questions c-f and j-k in our sleep assessment tool, as well as the primary question that leads off this part of the sleep assessment.
The first suspicious indicator is that the client does not feel rested even if a normal 7-8 hours are spent asleep in bed. While there may be other explanations for this, sleep apnea should be high on the list of possible reasons for persistent sleepiness when no other medical reasons can be determined. Given that sleep apnea may be present in up to 7% of adults, clinicians should be acutely aware of the possibility of this disorder, particularly with clients who are overweight.
If the client reports a history of waking up gasping for air, or if a partner reports a history of severe snoring or cessation of breathing when the client is asleep, these indicators are clearer evidence that a referral for medical examination is warranted. Morning headaches are also associated with sleep apnea, although there can be a number of other causes for morning headaches.
Another important question is question “h” - for two different reasons. In one kind of sleep apnea – obstructive sleep apnea (G47.33). - breathing is interrupted by physical obstructions to a person’s airway. This can be caused by physiological problems to how a person’s airway is positioned in the throat, or by extra weight in the neck pressing down on the airway, closing off the supply of oxygen to the lungs. If a client has gained a substantial amount of weight, it increases the possibility that sleep apnea may develop.
Weight gain is also often a result from extended sleep difficulties, for reasons that will be examined later in this course. Questions j-m also solicit information about problems that can occur as the result of persistent sleep insufficiency. When you see evidence of a constellation of problems that includes weight gain, changes in mood, increases in blood pressure, and a noticeable decline in a person’s sex drive, this is all circumstantial evidence that sleep insufficiency may have been occurring over time.
Other causes must be ruled out, including depression, thyroid and other metabolic problems, and a wide variety of other medical problems, but sleep apnea is a common enough disorder that it must be relatively high on your list of things to rule out.
This is the case even when the person in your office is not overweight in any way. When people think of sleep apnea, they are most likely to picture an overweight, middle aged man who has problems with snoring. While there is some validity to this stereotype based upon the statistics, this is only part of the story. There are actually several ways that the breathing problems can occur.
While it is true that extra pounds in the neck can lead to the development of obstructive sleep apnea, it is entirely possible for a very thin person to have obstructive sleep apnea based upon congenital deformations in how the airway is shaped or positioned. If you see the signs of severe sleep deprivation in a very thin person, don’t dismiss the possibility that he/she may have obstructive sleep apnea.
In another kind of sleep apnea – Idiopathic Central Sleep Apnea (G47.31) – the brain’s central systems for regulating the breathing rate malfunctions, missing important signals from the decreasing oxygen levels and increasing carbon dioxide levels. When the body misses these signals, it can cause insufficient levels of respiration, which in turn creates a kind of smothering effect as carbon dioxide levels become elevated. The smothering effect is what causes people to wake up. Clients of any size and shape can present with idiopathic central sleep apnea, as this is a primarily neurologically based problem. Prevalence for this problem is believed to be just under 1% of the adult population.
Central sleep apnea can also be induced from other medical disorders, for example, by brain stem trauma or neurodegenerative diseases such as Parkinson’s. (NIH/Medline Plus) In some of these cases the treatment of the underlying conditions may be sufficient to reduce or eradicate the presence of the condition, precluding the need for some of the other treatment approaches.
Central Sleep Apnea may also have two other etiologies, each with a separate diagnosis. Cheyne-Stokes breathing (R06.3) is a complex pattern of breathing, where changes in the levels of carbon dioxide in the blood pursuant to increases and decreases in respiration rate trigger episodes of apnea and compensatory hyperventilation in a cycled manner. This breathing pattern is most frequently seen in patients with congestive heart failure and other kinds of organ damage and failure. Approximately 50% of all patients with congestive heart failure experience this cycle of breathing during sleep.
Hospital, nursing home and hospice professionals are most likely to encounter this kind of sleep apnea. Diagnosis of this disorder should only be made by a medical professional, but mental health professionals should be aware of this diagnosis and the implications in terms of effects from sleep deprivation that accompany this disorder.
Central sleep apnea comorbid with opioid use (G47.37) is likely to be encountered by mental health clinicians who work in hospital settings where patients are receiving opioid medications for pain relief, or emergency rooms or substance abuse treatment facilities that provide services to patients with a history of opioid abuse. Opioids may have effects on certain areas of the brain that are involved in regulation of respiratory rhythms and functions.
As with Cheyne-Stokes breathing, diagnosis of this disorder should only be made by a medical professional. However, mental health professionals will need to be aware that sleep deprivation will accompany this disorder, and this can contribute to anxiety and depression over and above the CNS depressant effects of the opioids and the symptoms that may accompany withdrawal.
Additionally, research also indicates that sleep apnea accompanying chronic opioid use can produce increased morbidity and mortality. (Correa et al.) Patients with a history of opioid abuse may need to be assessed for problems with sleep apnea as a precautionary measure due to this factor.
There is also a third kind of sleep apnea – complex or mixed sleep apnea– that is a combination of both other kinds of sleep apnea. As we will see later in this course, sleep deprivation can increase the likelihood of gaining weight, so a person with central sleep apnea is a good candidate to add weight and increase the risk of developing obstructive sleep apnea as well. And for reasons not fully understood, a person with obstructive sleep apnea will also sometimes develop complex sleep apnea. (Morgenthaler et al., 2006)
It is important to note that most people – even clinicians – are likely to view sleep apnea as a somewhat rare disorder, affecting a relatively small number of people. As a result, sleep apnea is under-diagnosed and under-treated, leaving many people downstream from what is essentially a profound lack of sleep. It is believed that only about 10% of sleep apnea cases are ever diagnosed. (National Sleep Foundation, 2009)
For the record, it is estimated that up to 24% of middle aged men and 9% of middle aged women have some kind of sleep disordered breathing. (Young et al., 1993) In total, it is believed that up to 42 million Americans have some form of disordered breathing that interferes with sleep (Young et al., 1993), with up to 18 million Americans suffering from obstructive sleep apnea, the most common of the three different kinds of sleep apnea. (National Sleep Foundation, 2009)
This is to say that approximately one out of every fifteen people in America have their sleep affected by some form of disordered breathing. (Young et al., 1993; Lee et al., 2008) This represents a whole lot of sleep insufficiency. From a very practical perspective, it is important that clinicians be much more attuned to the possibility of sleep apnea in clients who present with signs of anxiety and depression.
Additionally, there are also reports that the incidence of sleep apnea is increasing in the United States most likely because of the increase in the prevalence of obesity. As people gain weight, they become more susceptible to obstructive sleep apnea. Therefore it is likely that increasing numbers of clients will be arriving at the doors of mental health clinicians with this condition.
Assessment of and Treatment for Sleep Apnea
It is difficult to anticipate how a client informed of the possibility of sleep apnea will respond to that information. There may be relief to have a medical reason for their difficulties, or there may be shock and dismay at the potential implications. However, it is the job of the mental health clinician to help the client process the information and make good decisions about how to proceed. In order to accomplish this dual task, it is very helpful for the clinician to be prepared to answer some preliminary questions about what approaches are used to diagnose sleep apnea and treat sleep apnea. This is particularly important for a client who is resistant or reluctant to address this issue.
Typically the next step in securing an accurate diagnosis of sleep apnea will consist of a referral to a sleep disorders clinic so that a sleep study can be conducted. In instances where the client has a primary care physician, the PCP would take the lead in making those arrangements and assuring that the client follows through with the recommendation.
In the event that the client does not have a PCP, it is preferable for the clinician to attempt to persuade the client to develop a relationship with a PCP who can coordinate the client’s overall care, including the sleep issues. The PCP will possess the medical knowledge to handle that role more successfully. However, in cases where the client is reluctant or resistant to that idea, it may be more effective to roll with the resistance and make the referral directly to the sleep clinic. Except in unusual situations, the sleep clinic will probably support the idea of the client finding a PCP.
Because sleep apnea is much more prevalent than most people know, it is quite important for clinicians to know which sleep clinics exist near them, and have some sense of the quality and professionalism of the services provided. It is also useful to have some clarity about the costs of a full-blown sleep study – in order to prepare the client for sticker shock – and to help the client work with their health insurance provider to clarify what costs will be picked up by insurance. The study is likely to cost somewhere between approximately $1000 and $5000, with some clinics charging a slightly reduced rate if insurance is not used.
A thorough sleep study, or polysomnogram, will generally involve having the client stay overnight and sleep at the clinic with a number of electrical recording instruments being attached to his/her head, face, hand/finger and trunk, as well as equipment attached to his/her nostrils to measure breathing. These connect to sensitive equipment that can monitor the client’s movements through the various stages of sleep and detect if the client is exhibiting the respiratory problems associated with sleep apnea and/or other sleep problems. For some people, the discomfort of the attached equipment can make it somewhat difficult to fall asleep, but often people with true sleep apnea are so continuously exhausted that this is not a concern.
As noted previously, there are three different manifestations of sleep apnea, and the polysomnogram will provide useful information in determining whether sleep apnea is present and which type of sleep apnea is contributing to the sleep disturbance. Because the etiologies are different for obstructive sleep apnea and central sleep apnea, there are somewhat different treatment regimens that may be recommended.
As noted, the use of opioid medications may also be a precipitant for central sleep apnea, and the recalibrating of the medication dosage may be sufficient to address this problem. (Obviously clients who misuse opioids recreationally may also precipitate central sleep apnea, and the treatment of choice in this instance would be to carefully support their move towards abstinence.)
There are also medications that may be prescribed for central sleep apnea under specific conditions, for instance acetazolamide when central sleep apnea is present at high altitudes. (Mayo) However, there is not unanimous agreement on the efficacy of these drugs, pending further research.
More frequently, the treatment of choice for central sleep apnea consists of one of several medical devices that use a breathing tube or breathing mask to provide a supply of pressurized air or more concentrated oxygen to patients while they are sleeping. The most common and well known of these devices is a Continuous Positive Airway Pressure (CPAP) device, which is used for all three sub-types of sleep apnea. It delivers a constant stream of pressurized air into the lungs of the sleep apnea patient, precluding the loss of oxygen that leads to instances of waking up. (Mayo)
A similar device, called a Bilevel Positive Airway Pressure (BPAP) device, operates with the same fundamental mechanical principle, but is set up to deliver a higher level of air pressure upon inhalation and a reduced level of air pressure upon exhalation, boosting the weak breathing pattern of central sleep apnea. (Mayo)
A number of studies suggest that a third device, the Adaptive servo-ventilation (ASV) system, may be a more effective machine for central sleep apnea and complex sleep apnea. (Mayo) This device has a built-in computer that monitors and analyzes a patient’s normal breathing pattern and uses this information to regulate the delivery of the pressurized air in a synchronized way with the patient’s breathing pattern.
Obstructive sleep apnea is treated using these same options for breathing assistance, with the CPAP being the most frequently utilized device. However, there are other non-mechanical treatment options that are sometimes used. First, obstructive sleep apnea is often the result of impingements to the airways by excessive weight gain in the area of the throat and windpipe. If the patient is able to reduce the excessive weight, it is possible that the sleep apnea can be reduced or eliminated.
In other cases, the obstruction is the result of a physiological deformation within the throat or airways that causes an obstruction to the smooth passage of air when the patient is asleep and lying down in certain positions. In some instances, Positional Therapy is indicated, where the patient is taught to avoid sleep on his/her back, using devices that impede assuming that sleep position. It is reported that this is more frequently used in instances where the sleep apnea is relatively mild. (Sleepapnea.org)
There are also oral devices worn in the mouth during sleep that help to reposition the throat and airway for better breathing. These appliances work by positioning the lower jaw slightly forward of its usual rest position, and have been shown to be effective in many instances. (Sleepapnea.org)
For some patients, it may also be helpful to consider throat surgery to repair the physiological abnormality. Such surgeries have been reported to have a success rate of about 50%. (Sleepapnea.org) On a cautionary note, however, it is often difficult for a surgeon to know precisely where in the throat the abnormality is found, and surgery does not always effectively repair the physiological problem on the first try.
It is also important to note that children may develop sleep apnea due to physical deformations, most often caused by enlarged tonsils or adenoids. (Sleepapnea.org) Removal of the tonsils or adenoids is the treatment of choice in these instances.
Mental health clinicians are reminded not to become involved in influencing clients about which treatments to undertake in addressing any presentation of sleep apnea. These are medical decisions that should be left between the client and his/her PCP and/or sleep specialist. The information in this section has only been presented as a tool for clinicians to understand what may be involved in the assessment and treatment of sleep apnea so that the clinician can be better prepared to answer questions and address the client’s reluctance or resistance to seeking necessary treatment.