Whether you are a specialist or a general practitioner, there is a good chance that the medical problems you treat are themselves useful screening criteria for seemingly unrelated disease conditions that require prompt attention. Perhaps no aspect of clinical medicine correlates with this axiom greater than sleep disorders: the health issues that non-sleep specialists treat are often strong positive indicators of Obstructive Sleep Apnea (OSA) – a condition whose long term impact and associated morbidity is often more serious than the complaint for which the patient arrives. As a result, if we keep our eyes open for conditions associated with sleep disorders, we all have the opportunity to help our patients not just once, but twice.
Consider the high rates of erectile dysfunction and kidney stones found in patients with OSA: A thoughtful urologist who has referral access to a user-friendly sleep service has the opportunity to relieve tremendous suffering in the patients with these diseases – but could also save the life of an undetected sleep apnea patient whose very presence in the urologist’s office may be a sign of the increased mortality risk from heart attacks, stroke and car accidents that arise from OSA. Though sleep apnea is not generally considered the purview of a urologist, there is no reason it could not be – especially if that urologist has the option of referring the patient to a web-based virtual platform that gets the patient treated in days, and almost immediately reduces the risk of potentially fatal disease.
The same goes for a psychiatrist who sees a male over 40 with new onset depression; a gynecologist who sees a fatigued woman in menopause; or a cardiologist who treats atrial fibrillation: They can each help the patients for the issues that bring them to the office, but they could help them again – and just as meaningfully – with a simple referral to an accessible consultation for sleep apnea, which is associated with each of these conditions.
With that in mind, what follows is a list of issues customized for a clinical geriatrician, including those that work in concierge practices, each of which should prompt the expedient evaluation of the patient for OSA.
Hypertension: More than a third of patients with high blood pressure have OSA, even in well-controlled patients. But if a patient has resistant hypertension (uncontrolled with 3+ medications), those patients suffer an OSA incidence between 70-80% – and the hypertension is likely to remain resistant until the OSA is addressed.
Depression and Anxiety. Though the incidence of OSA amongst patients with mood disorders is not exactly known, it has been established that half of all OSA patients have depression and/or anxiety. If your patients are coming to you with a mood disorder, it would make sense to refer them to platforms that offer accessibility and ease of use in the evaluation and management of sleep apnea.
Stroke and TIA: This connection is well-established: Stroke is one of the leading causes of mortality amongst patients with OSA, and TIA should be viewed as a warning shot to address sleep disordered breathing. The traditional system of diagnosing OSA, with specialty consultations and overnight sleep studies, can take months – and with OSA causing more than two excess mortalities per 1,000 untreated person years, delayed care with a safe therapy (PAP) is difficult to justify.
Atrial fibrillation (AF): In cardiology clinics, 50% of patients with AF have OSA. If the OSA is not treated, it will be much more difficult to control the AF, as well as reduce the morbidity and mortality associated with this common dysrhythmia.
Cognitive Impairment and Alzheimer’s Disease. The presence of OSA doubles the risk of mild cognitive impairment and dementia. In many cases, the disease state cannot be reversed, but positive airway pressure therapy (PAP) may slow progression. Patients with signs of dementia, including early signs, likely need to be evaluated in a certified sleep center – but otherwise healthy patients who are reporting mild memory problems may be candidates for more expedient platforms.
Nocturia. Don’t blame it on the prostate alone: the increased intrathoracic pressure associated with apneic events increases release of Atrial Natriuretic Peptide (ANP), promoting diuresis and increased awakenings. As many as 70% of OSA patients, females included, experience nocturia, and PAP significantly reduces these episodes.
Osteoporosis. Patients with OSA have higher rates of osteoporosis, lower lumbar bone mineral densities, and lower lumbar T-scores. Complicating matters is that OSA is often overlooked in women, and the OSA symptoms they experience are often misattributed to menopause alone. What is unusual in this population – concurrent OSA and osteoporosis – is that these patients often have a lower BMI.
All doctors, particularly specialists, should be cognizant of our tendency to see clinical presentations through the prism of our specialty training. Sleep is such an important pillar of health that all of us should consider its disturbance as a possible “upstream” cause of the medical problems we routinely and expertly handle.
If any of these clinical conditions commonly present in your practice, it’s worth considering the possibility of Obstructive Sleep Apnea (OSA) as their cause. Untreated OSA can have serious health implications, but the good news is that effective treatments are available. Refer your patients to Konk Sleep to explore their options and take the first step toward better sleep and improved health, all without leaving their homes.