For almost a decade between 1995 and 2005, cinematographer Madhu Ambat had been feeling excessively tired and sleepy. “I would sleep anywhere, anytime,” he said. Ambat and his wife Lata always thought that his fatigue and general listlessness were because of his hectic, erratic work hours. Ambat got enough sleep but would snore a lot.
“He would snore in such a way that he would take in a lot of air, up to almost 20-30 counts,” said Lata, who would be disturbed by the snoring. “But it wouldn’t come out immediately. It comes out in short, sudden intervals almost like firecrackers bursting.”
It was only when she read an article about sleep apnea in The Reader’s Digest in the 1990s that they saw a connection between the snoring and daytime sleepiness. But at the time, Ambat did not know anyone in India who could treat the problem, so they “put up with it”.
Obstructive sleep apnea is a sleep-related breathing disorder in which muscles at the back of the throat tend to relax during sleep, thereby blocking the airway. Since sleep medicine is a relatively new practice in India, there have been only a few studies on the extent of sleep disorders in the Indian population.
A study conducted between 2003 and 2005 involving of participants between the ages of 30 and 60 from South Delhi district found that the estimated prevalence of obstructive sleep apnea among the Indian population was 9.3%.
Just like Ambat, many of the participants of this study complained of daytime sleepiness and constant fatigue. Any amount of sleep was not refreshing. Many even reported choking at night. Doctors say that headaches and body aches are often a fallout of this inability to gain complete rest.
Haricharan, a movie director in Chennai, struggled with obstructive sleep apnea from 1995 until he got it treated in 2007. Every night, he would wake up with a start, unable to breathe. His wife, Rekhs, said that her sleep has been pften disturbed because of her husband’s condition.
“You are lying down next to the person and seeing them suffer the whole night,” said Rekhs. “I don’t think I’ve had a good night’s sleep for twelve years.”
The obesity effect
Obstructive sleep apnea is especially common among people suffering from obesity who have sedentary lifestyles. Doctors say that people at high risk of developing the condition are usually overweight, male and with a family history of sleep apnea.
According to Dr Manvir Bhatia, senior consultant in neurology and sleep medicine in Delhi, between 60% and 70% of people who are morbidly obese develop sleep apnea. “The more weight around the neck, more chance you will have of getting sleep apnea,” she said. In such cases, soft tissues around the throat relax more than normal, blocking the airway.
The reverse holds true as well. Sleep apnea can cause obesity.
“During an apneic event, the release of two hormones that regulate appetite and satiety – what I eat and how much I eat – go haywire,” said Bhatia. “Your desire to eat increase and satiety does not get fulfilled. Patients usually have a craving for starchy and sweet things, and so tend to put on weight.”
Also, fatigue leads to lack of exercise and lethargy, which contributes to weight gain, she added.
But there are other causes too. Doctors say that physical attributes that put you at risk for obstructive sleep apnea include a deviated septum, receding chin, or enlarged tonsils or adenoids. Allergies or other medical conditions that cause nasal congestion and blockage can also contribute to sleep apnea. Smoking and alcohol consumption can also lead to restricted airway and increase the likelihood of snoring.
In Madhu Ambat’s case, his throat muscles were sluggish because of a severe case of whooping cough he had as a child and could be the main reason for his sleep problems.
Spotting the problem
One day in 2006, Ambat fell asleep while waiting outside a hospital ward in a Chennai where his wife had been admitted for a surgery. While passing by the ward, sleep specialist Dr N Ramakrishnan observed Ambat’s breathing pattern and told Ambat’s friend that he seemed to have sleep apnea.
After the initial clinical evaluation by Ramakrishnan, Ambat’s sleep activity was recorded on a polysomnogram machine, which noted his heart rate, breathing, blood oxygen level and his brain waves. The next day, Ambat found through the results of the polysomnogram that he had been waking up at least 40 times over ten hours of sleep. And he had never realised it.
Sudhir Pandey, a resident of South Delhi was also diagnosed with a similar problem. After suffering with symptoms of excessive sleepiness and high blood pressure, he visited a sleep clinic in Delhi where he was diagnosed with sleep apnea.
“He would sleep all the time, sometimes even while talking or eating,” said his wife Indu Pandey. “For whole year, he hardly went to work. His memory also suffered. We could not figure out why his health was worsening.”
After examination, Bhatia explained to Pandey that his brain was not getting enough oxygen when he slept and so his brain could not rest, even as the rest of his body did. This lack of rest had caused Pandey’s high blood pressure and sugar problems.
“When the patient has an apneic event,the sympathetic nervous system gets activated and a lot of chemicals get release,” said Bhatia. “This causes a steroid-like effect, which pushes the blood pressure and sugar levels up. If not treated, atleast 30 to 40% patients with sleep apnea will land up with high blood pressure.”
Both Pandey and Ambat now use a Continuous Positive Airway Pressure machine every night while sleeping, which allows them peaceful sleep. The machine increases the air pressure in the throat so that it does not collapse between breaths.
“The few masks I used were not very comfortable,” said Ambat. “I had to try two or three different masks to find the right one for me. Now I’m able to sleep well at night, without snoring or waking up. I don’t have the same daytime tiredness anymore.”
Before visiting a sleep specialist, both had attempted to deal with their problem in different ways. Pandey had approached a psychiatrist to find out why he was sleeping so much. Ambat had been advised to get a surgery to correct the deviation of his septum to rid him of snoring. But even after the surgery he did not feel much better, he said.
“If an incorrect surgery is performed, sleep apnea does not completely resolve and the patient may have to use the PAP machine even after a surgery,” said Dr Preeti Devnani, clinical director at Sleep Disorders Clinic in Mumbai. “Sleep medicine is multidisciplinary and ENT does play a crucial role, however it is better when an entire multi-discipline team is caring for the patient.”
She added that the treatment for sleep apnea is dependent on the condition of the patient along with its severity. While Positive Airway Pressure machines do help in dealing with sleep apnea, there are different kinds of sleep apnea machines that are available and are prescribed based on patients’ needs.
Dr Prashant Chhajed, director of the Lung Care and Sleep Centre in Mumbai, explained that the patient is usually put through two kinds of sleep studies, before recommending a particular kind of device or treatment. The first sleep study is diagnostic in nature, where the sleep patterns are studied. If the patient is diagnosed with sleep apnea, they are put through a second sleep study which is therapeutic in nature, where the patient is asked to sleep with the device on.
“There is a lot of simple education that is involved so the patient knows what to expect,” said Chhajed. “Counseling remarkably reduces the fear.”
Devnani’s Sleep Disorders Clinic treats the entire spectrum of sleep disorders like sleep apnea, insomnia and sleep insufficiency syndrome, among others. Of the patients that seek treatment here, approximately 60% of them have sleep apnea.
Men are twice as likely to have sleep apnea as women, said Devnani.
Devnani explained that one theory that supports why men are more prone to sleep apnea is related to pharyngeal mechanics. Men have larger pharynx than women and experience significant changes in airway sizes with position. As men age, their upper airway is more prone to collapsing as compared to women.
However, she adds that men are often diagnosed with sleep apnea almost eight times more often than women, since women tend not to seek medical attention particularly for sleep problems. Chhajed also agreed with this, saying that women are often under diagnosed as they are not forthcoming about symptoms like snoring.
Symptoms of sleep apnea presented by men and women may also vary.
While men tend to have more noticeable and reportable symptoms such as snoring and choking, women have more neurocognitive and neuropsychiatric symptoms such as mood changes, along with headaches and chronic fatigue, said Devnani. Sleep apnea causes hormonal irregularities as hormone secretion is linked to sleep duration and quality.
These might go unnoticed by a physician during initial evaluation of a patient, said Devnani.
According to Devnani, women’s risk for developing obstructive sleep apnea increases as they transition through menopause. “Women are three times more likely to have post-menopausal sleep apnea than pre-menopausal,” she said. Reasons for post-menopausal obstructive sleep apnea include weight gain and unclear hormonal changes.
Haricharan never even heard of sleep apnea until, in 2005, he visited sleep practitioner Ramakrishnan. He had been suffering from the condition for almost 12 years.
Ramakrishnan said that there is more awareness about sleep disorders now. He started Nithra Institute of Sleep Sciences in 2004, which remains one of the only clinics exclusively for sleep-related disorders in Chennai. At that time, he would receive only one patient a week. But now, he gets between 20 and 30 patients a day. About 40% of the patients who visit his clinic report symptoms of sleep apnea, which include snoring and excessive daytime sleepiness.
A few years ago, the clinic conducted a study where they looked at how 1,000 consecutive patients came to hear about the clinic. They found that only 36% of the patients were referred to them by other doctors, while the rest found out about the center through the internet and media reports.
“That goes to say that awareness has to be created among doctors on sleep problems,” said Ramakrishnan. “When you go for any health check up, doctors ask you questions about various things – including what surgeries you have had, but usually they don’t ask you about sleep.”
Patients of sleep apnea also look out for fellow sufferers, said Chhajed. “Patients of sleep apnea often diagnose others and refer them to sleep clinics,” he said. “This pool of referrals is gradually growing.”
Liek Ambat and Pandey, Haricharan has now taken time to find the air pressure masks that fits him and is now able to sleep well.
“People gave us all sorts of bizarre advice before we went to the sleep clinic,” said Rekhs. “They told us to try voodoo and black magic to cure this. But all you have to do is wear a mask while sleeping every night. We are both finally able to sleep peacefully.”