Q & A: When Sleep Apnea Looks Like Insomnia

Keisha was wondering whether to have a sleep study.

“I asked my doctor to give me something for my insomnia,” she wrote, “but he wants me to have a sleep study first. He thinks I might have sleep apnea. I don’t think I do. I don’t snore (as far as I know). I wake up a lot at night but I’m not short of breath or gasping for air.

“Besides, how could I get any sleep at all with those wires attached to my head! You say sleep studies aren’t helpful for people with insomnia. So what’s your opinion here? Should I have a sleep study or will it just be a waste of my time?”

insomnia and daytime sleepiness may actually be sleep apneaKeisha, a 37-year-old graphic designer, wrote to Ask The Savvy Insomniac recently with a question about having a sleep study.

I asked my doctor to give me something for my insomnia, she wrote, but he wants me to have a sleep study first. He thinks I might have sleep apnea. I don’t think I do. I don’t snore (as far as I know). I wake up a lot at night but I’m not short of breath or gasping for air.

Besides, how could I get any sleep at all with those wires attached to my head! You say sleep studies aren’t helpful for people with insomnia. So what’s your opinion here? Should I have a sleep study or will it just be a waste of my time?

When Is a Sleep Study Useful?

Keisha is right: I’ve blogged about sleep studies before because I’m skeptical about their value for people with simple insomnia. As conducted and scored today, they do very little to help insomniacs other than rule sleep apnea and other sleep disorders out.

But if a doctor suspects you have sleep apnea, it’s important to verify that objectively. A sleep study is then in order, at a sleep clinic or with one of the newer devices for use at home.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a serious problem. During sleep, the tongue falls back against the throat, collapsing the upper airway. This keeps you from breathing, deprives you of oxygen, and increases your level of carbon dioxide until you wake up enough to start breathing again.

OSA compromises the sleep you get, leaving you sleepy and prone to mistakes and accidents. It also leads to serious health problems. Repeated episodes of apnea stress the heart, increasing your susceptibility to hypertension, heart attacks, and other cardiovascular diseases. It’s also associated with weight gain, type 2 diabetes, inflammation, asthma, and acid reflux.

In short, it’s nothing to fool around with.

Often Looks Like Insomnia

But here’s the problem: In most cases, people with OSA are not aware of these repeated awakenings because they occur beneath the level of consciousness. Convincing support for this assertion came in a review of medical records published in the December 2014 issue of Mayo Clinic Proceedings. Take a look at some numbers here:

  • Of 1210 insomnia patients presenting at a sleep clinic in Albuquerque, New Mexico over a period of 8 years, about three-quarters (899) were using sleep aids regularly or occasionally. The majority of these—710—were using prescription sleeping pills. The rest were using over-the-counter sleep aids.
  • None of the 899 medication users reported improved sleep. So they, as well as the others, whose sleep had failed to improve following drug-free insomnia treatments, were seeking further assistance.
  • All of the patients were verbally screened for OSA. Then 942 underwent sleep studies.
  • About 91 percent tested positive for moderate to severe OSA. Yet a screening tool used by many primary care physicians to ascertain the likelihood of sleep-disordered breathing failed to detect it in 32 percent.
  • What’s more, the patients taking prescription sleeping pills were least likely to report symptoms of apnea and the most likely to report severe insomnia and other health problems.

In other words, it’s easy to mistake OSA for insomnia, and primary care physicians may do the same. You’re then treated for insomnia when you should be treated for apnea, compromising your quality of life and increasing your vulnerability to heart and other serious health problems down the line.

The Take-Away

Occasionally I hear from people like Keisha who doubt that a sleep study could tell them anything they don’t already know. There’s a chance they could be right. On the other hand, this is one instance when what you don’t know could end up hurting you a lot. And now, with much less expensive home testing devices available, there’s less reason for concern about cost.

If your insomnia takes the form of waking up several times at night and if, after being interviewed by your doctor, he or she suspects you might have OSA, bite the bullet and have the test. Insomnia is no picnic, but untreated apnea is worse.

Sleep Studies: The Answer to Insomnia?

People pop the question whenever I mention my long struggle with insomnia: “Have you had a sleep study?”

When I say “no,” they always look puzzled. Wouldn’t I want to get to the bottom of a problem that’s had such an impact on my life?

sleep-studyPeople pop the question whenever I mention my long struggle with insomnia: “Have you had a sleep study?”

When I say “no,” they always look puzzled. Wouldn’t I want to get to the bottom of a problem that’s had such an impact on my life?

Back and Forth

I considered having a sleep study done in the 1990s, when my sleeplessness at the beginning of the night morphed into insomnia surf ‘n’ turf.

Trouble getting to sleep? As frustrating as ever.

Trouble waking up early? Now I had that, too. Not to mention that a snort or quiver from my husband in the middle of the night could blast me through the roof. Once I was awake, it took me ages to fall back to sleep (if in fact I did). I never knew when sleep would come or how long it would last.

My strategy was to read myself to sleep in a comfortable armchair, but there were nights when by 3 a.m. it was clear I wasn’t going to sleep at all. These all-nighters were no fun. I sought relief from the anxiety they created by plopping down in front of my Mac Classic, whose 24-hour companionability, together with a glass of wine, helped ease my tension till dawn.

There were also catch-up nights when I slept a whopping 6½ hours. More than six hours has always been a long sleep for me—the equivalent of 8½ or 9 hours’ sleep for most other people I know.

If I spun the Wheel of Fortune by going in for a sleep study, on which kind of night would the wheel come to rest? And how could a single night possibly serve as representative of the whole? A week’s worth of sleep studies would be needed to capture what was going on with me at night.

What Sleep Studies Can and Can’t Do

Years later I did call to inquire about having a sleep study at a research institution nearby. A screening technician asked a series of questions and then she told me that in my case, a sleep study would not be advised. Later I found out why.

If my answers had suggested I might have sleep apnea (obstructed breathing), seizures, heart trouble or movements such as occur in people with restless legs or those who act out their dreams, the screener’s verdict would have been different. These problems, which cause poor sleep, are the ones sleep studies can readily identify, and identification points the way to treatment.

But the conventional sleep study has not helped much in the diagnosis and treatment of primary insomnia, which is what I have. In fact, up to 50 percent of the time, the brain activity in insomniacs looks the same as brain activity in champion sleepers who report getting 7 or 8 hours’ sleep a night. Sleep studies are useful for insomniacs only when a clinical interview does not yield a clear diagnosis, traditional treatments fail or violent behavior is suspected during sleep.

The Take-Away

If you’re considering raising the issue of a sleep study with your doctor, by all means do so if you’re overwhelmingly sleepy during the day, you snore or wake up gasping for breath, your legs feel jumpy at night or you wake up hurting in the morning.

Otherwise, save yourself $2,500 and a night trussed up like Thanksgiving turkey in a sleep lab. Find a doctor who will diagnose and treat your insomnia based on a thorough clinical interview, and you’re set.