Obstructive Sleep Apnea (OSA)

Imagine crashing on your bed after a long working day, drifting off to peaceful sleep, hoping to rest but repeatedly being jolted awake as short pauses in breathing break into this serenity. As unbelievable as something out of science fiction, such is the experience for millions diagnosed with Obstructive Sleep Apnea. OSA, in most cases, is a condition that the sufferer never notices, but it undoubtedly impacts their health and makes it difficult for the individual to sleep in the same room. From everyday difficulties like daytime fatigue to chronic issues like arrhythmia, the effects of Obstructive Sleep Apnea (OSA) can extend beyond the predominant case of poor sleep quality. 

What is Obstructive Sleep Apnea? 

Obstructive Sleep Apnea is a breathing-related sleep disorder characterized by repeated awakenings from sleep due to difficulty in breathing caused by upper airway obstruction. There are multiple interruptions in breathing because the muscles in the throat relax too much, temporarily blocking the airflow, which makes it challenging to maintain long periods of sleep. During this process, the brain is not getting enough oxygen, causing it to wake up briefly and resume breathing. 

According to the Diagnostic Criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), there is the presence of an Apnea-Hypopnea Index score of 5 or greater episodes of complete or partial upper airway blockage per hour of sleep and the presence of daytime symptoms, such as sleepiness and fatigue accompanied with excessive daytime sleepiness and diminished concentration.

The condition is understood as a medical disorder and is clinically diagnosed using the collected evidence of specific sleep studies like polysomnography or overnight home sleep testing. This condition is marked by distinct features like snoring, choking, gasping, or stopping breathing noticed by the bed partners before the sufferer understands what is occurring to them while sleeping. OSA can be characterized as mild, moderate, or severe based on the number of apneas and hypopneas an hour (VG et al., 2021).

Signs & Symptoms of OSA 

• Raucous Snoring: The most obvious symptom is that of loud snoring. However, not everyone who snores has OSA. Snoring associated with OSA is usually loud but may be less frequent, punctuated by pauses in breathing. 
• Breathing pauses during sleep: It is the hallmark sign of OSA, which can last for several seconds or even minutes and is usually accompanied by choking or gasping when the person resumes breathing. 
• Excessive Daytime Sleepiness: Typically, patients with OSA are daytime sleepers characterized by significant alterations in sleep and nocturnal cycles; they may, therefore, experience excessive day-time somnolence characterized by such feelings as, they are just excessively tired or quickly falling asleep during everyday activities like driving, at work, on attendance of social occasions.
• Early morning headaches: Some sufferers of OSA wake up having headaches caused by the variability of oxygen levels with carbon dioxide, which tends to build up in the person’s body through sleep.
• Nonrestorative Sleep Patterns: Repeated episodes of awakenings and frequent changes in sleep position at night because of difficulty breathing might lead to restless, non-refreshing sleep. 
• Difficulty in Concentration and Memory Issues: OSA may negatively affect cognitive functions like memory, attention, and concentration. Patients with undiagnosed or untreated OSA may describe that they are fuzzy or cannot focus well on their work. 
• Irritability and Mood Fluctuation: The chronic sleep loss associated with OSA may be related to irritability, mood swings, depression, or anxiety in some people. 
• Sore throat or dry mouth: Individuals tend to wake with a dry mouth or sore throat due to usually breathing through their mouths all night, considering the airway is blocked most nights. 

Causes and Associated Risk Factors

OSA can be brought about by many causes that are classified into modifiable and non-modifiable factors. The factors are as follows: 

Anatomical Factors 

• Enlarged Tonsils or Adenoids: These can cause a blockage in the airway, especially in children, increasing the tendency to develop OSA. 
• Obesity: Excess weight, mainly around the neck region, increases the tendency for a blockage. Deposits of fat on the throat may result in narrowing and collapse of the airway while asleep. 
• Large Neck Circumference: A more significant neck may thus tend to cause airway obstruction because the thicker neck would press on the airway muscles. 
• Chronic Nasal Congestion and Allergies: Allergies can cause chronic nasal congestion that results in disturbed airflow and might worsen the symptoms of OSA since a person could be sleeping with mouth open. 

Genetic and Structural Factors 

1. Family History: A genetic predisposition to OSA is usually passed down in families. Those patients with a personal history of family members having suffered from OSA are at higher risk of being diagnosed. 
2. Unconventional Jaw or Facial Configuration: The small jaw, overbite, and receding chin determine where the tongue and soft tissues at the throat tend to lie in the airway space, thereby potentiating airway obstruction. 

Individual Factors 

1. Age: The incidence of OSA increases with age, and the most common population is those older than 40 years. With advancing age, airway muscles weaken, causing more likely obstruction. 
2. Gender: The prevalence of OSA is higher in males compared to females. The risk factors increase among women due to a decrease in the hormones produced by the body after their menopause. 
3. Alcohol and Sedatives: Alcohol or sedative medications cause relaxation of the airway muscles, allowing it to collapse during sleep.
4. Smoking: Fluid retention and inflammation in the upper airway due to smoking can worsen OSA. 
5. Other Medical Conditions: Even hypertension, diabetes, heart disease, and stroke have an association with a higher risk of OSA. 

Difficulties In Daily Functioning 

Consequences on Cognitive Ability 

Sleep fragmentation extends beyond mere somnolence. Unable to obtain adequate deep and REM sleep contributes to several cognitive effects. Those who are untreated for OSA may experience a decreased ability to recall and learn. Focus also suffers due to insufficient rest for the brain, a function it receives during sleep, where it stores and interprets emotion. In turn, they become forgetful, unable to remember new information or have difficulty concentrating for long periods. 

The brain cannot process emotions properly, leading to mood disturbances, thus irritability, or even anxiety due to lack of deep, restorative sleep. Research studies have established that untreated OSA patients have an increased propensity to develop coronary artery disease among cardiovascular diseases. Fluctuation of oxygen levels with repeated surges and heightened sympathetic nervous responses causes systemic inflammation, one of the established risk factors for heart diseases. Additionally, the stress that is caused to the heart by continuous fluctuations in breathing and oxygenation might, therefore, tend to increase the chances of heart failure, especially in patients with other diseases. 

Metabolic and Mental Health Impact 

Untreated OSA contributes not only to cardiovascular complications but also to metabolic disorders, with an increased risk of obesity and type 2 diabetes. The sleep disturbance caused by OSA impacts the body’s level of hormones related to hunger and satisfaction – leptin and ghrelin. Continuous lack of sleep from OSA may increase the urge for calorie-rich foods, hence over-weighing. In addition, sleep disturbance produces insulin resistance that leads to an imbalance in blood sugar levels and, therefore type-2 diabetes.

OSA is also significantly related to mood disorders such as depression. The perpetual feeling of exhaustion and lack of quality sleep leads to psychological degradation characterized by irritation, moodiness, and even, in some people, depression and anxiety. The inability to have proper nighttime sleep amplifies stress levels and worsens the state of being more irritable for an individual dealing with daily situations (Arnaud et al., 2020). 

Treatment and Interventions for OSA: 

Surgical Interventions 

CPAP therapy is the most common and effective treatment for moderate to severe OSA. CPAP involves sleeping with a mask covering the nose (or both the nose and mouth), allowing continuous airflow and ensuring the airway is open. The treatment abolishes apneic events and enables the patient’s undisturbed, refreshed night’s sleep. CPAP is very effective in alleviating daytime sleepiness and improving cognitive function; however, most patients need some period of adaptation to the device. 

Cognitive Behavioral Therapy for Insomnia (CBT-I) 

In patients with OSA, insomnia usually arises as a consequence of sleep cycle disruption, which plays a significant role in the improvement of fatigue and stress symptoms accompanying the diagnosis. Cognitive Behavioral Therapy for Insomnia is a structured therapeutic intervention to help individuals deal with thoughts and behaviors that interfere with sleep. CBT-I is based on the principle that negative thoughts about sleep (e.g., “I’ll never be able to sleep well again”) can perpetuate sleep difficulties. By working with a trained therapist, individuals can identify these negative thoughts and replace them with healthier sleep habits. 

CBT-I also enables the patient to design a sleep-promoting environment and sets up regular sleep-wake patterns. Some techniques of CBT-I improve sleep efficiency and can get over the stress of anxiety, which is generated from the chronic deprivation of sleep in patients with OSA. There is evidence of effective improvement in sleep outcomes of therapy even if given along with CPAP therapy; this enhances the effectiveness of the treatment (Chang et al., 2019).

Support Groups and Psychoeducation 

The emotional cost of OSA can be eased by associating with others who experience the same conditions. Support groups provide a ground where people affected by OSA can share experiences, discuss options for treatment, and give each other mutual support. It may become one of the key comfort-giving factors, especially as many patients suffering from chronic health issues tend to isolate themselves. 

Conclusion: 

Obstructive Sleep Apnea is a chronic sleep disorder that impacts the quality of sleep and quality of life, leading to serious complications like cardiovascular diseases and metabolic abnormalities. By increasing awareness about this condition, individuals can be treated through medical and psychological interventions to prevent the long-term effects of this condition.