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Sleep Disorders

Untreated Obstructive Sleep Apnea

05/04/2009

Question:

In the past 2 years my husband age 62 (now) has had a menegioma (large) removed from the entire frontal lobe of his brain, and the last 6 months a quad bi-pass. Before all this began he was diagnosed with sleep apnea, severe. He stopped breathing like 92 times in an hour. He refused to wear the CPAP machine, then after all of the above happened.

He still refuses to treat it. After his bi-pass the doctor told him, either treat this or die. That only made my husband MAD. He has brain damage from the tumor and has frequent (every day) bursts of anger. Now he is constantly asleep, in his chair, he leans forward in it and sleeps, wakes very little, to go to the bathroom and if I wake him for meals. He huffs and puffs to even move around, but he is exhausted all of the time. He can sit in the car and in 2 minutes he is sleeping. I have begged him to do something to wear the CPAP he has and he just gets angry (is this due to brain damage or lack of sleep?) I am worried I will find him dead one morning. Also his sleep is quite sound. It is hard to wake him. Is this level of sleep apnea deadly?

Answer:

First, let me express my sincere empathy with you and your husband. I will then try to take on one question at a time.

His obstructive sleep apnea (OSA) is very severe. The consequences of this condition can be serious and range from a poor quality of life (morning headaches, disabling sleepiness, poor concentration, irritability, etc) to potential problems with blood pressure control, heart disease and strokes. Patients with OSA do not stop breathing and die in their sleep, rather their brain, deprived of oxygen, awakens and makes them take a few breaths before returning back to sleep. This protects the individual from experiencing severe problems on any given night. The cardiac complications tend to develop over several years when the sleep apnea is untreated. However, with effective treatment, the impact of OSA on cardiovascular complications is significantly reduced.

The fragmentation of sleep resulting from the recurrent breathing pauses can lead to sleep deprivation and deprivation of oxygen throughout the night. Both of these can result in daytime sleepiness and even behavioral changes. Depression is worse in patients with OSA, and OSA increases the risk of developing depression. The anger or aggression that your husband demonstrates is possibly consistent with frontal lobe release more so than with OSA, however, the severe OSA he has may be a contributing factor to his behavioral changes. And while patients with OSA can be quite irritable, they usually do not become aggressive.

Another confounding issue is that both his of his conditions (OSA and brain tumor-surgery) can result in sleepiness, although, I agree with you that his OSA is the more likely explanation for his sleepiness. What can you do? It is ideal that he gets on CPAP. CPAP therapy is prescribed for most patients with OSA because it works very well and, with patience, motivation and close follow-up, most patients can get used to using CPAP on a nightly basis. In a large number of well-done studies, CPAP therapy has been consistently shown to be effective at improving a number of measures of quality of life, including daytime alertness, improved concentration and improved mood. In addition, growing data suggest that CPAP may reduce some of the medical consequences associated with sleep apnea.

You can tell him that there are advances in the technology of CPAP and mask interfaces and that, with proper equipment, he may be able to better tolerate CPAP therapy. If, however, he is not able to use CPAP at all, then in some cases, surgery or oral appliances can be effective treatments for OSA, though this is in the minority of patients with OSA. Based on the severity of your husband's sleep apnea, it's unlikely that either of these will be reasonable treatment options, unless he is willing to consider a tracheotomy. At present, there are no known medications that are effective at treating sleep apnea and these are generally not considered part of the treatment plan.

Alternatively, he may need to use oxygen at night, as a second line treatment. Oxygen may help maintain some degree of oxygen delivery to his brain and heart, though it will not keep his airway open during sleep. So, while oxygen might help with low oxygen levels in sleep, oxygen will not improve his sleepiness.

Another possibility to consider is that his sleepiness may be due, in part, to what is called "organic brain syndrome" (the fact that he had a tumor and resection of a part of his brain). If this a felt to be a major factor, then a trial of stimulant medication may be helpful in improving the degree of sleepiness, and possibly the component of his behavior that is attributed to his sleepiness.

As you can see, the situation may be complex and will require input from a number of specialties. It would probably be worthwhile having your husband see a neurologist as well as a sleep specialist. Together, these physicians can devise a treatment plan that your husband may find acceptable. Additional help from other specialists may be required.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University