Joseph M. Ojile, M.D., D.ABSM, F.CCP
Chief Executive Officer, Clayton Sleep Institute
Over the last few months we’ve seen a spike in patients who’ve come to see us because “my blood count is too high.” The patients are puzzled. Why am I seeing sleep specialists when “I have too many red blood cells?” They’re seeing us because they have very smart, deeply caring primary care physicians.
So let’s look at the possible ties between an elevated hematocrit (the measurement of red blood cell count relative to blood volume) and sleep disorders.
One example patient, a 68-year-old gentleman, had a hematocrit measurement above the normal range despite as well as a hemoglobin measurement above normal range. Hemoglobin is the protein contained in red blood cells that delivers oxygen to tissues. Elevated hemoglobin and hematocrit are important markers for erythrocytosis—“too many red blood cells.”
Our patient had been diagnosed with Obstructive Sleep Apnea several years prior, and was using a CPAP, but reported that he had excessive daytime sleepiness and that he did not feel rested despite the CPAP treatment.
Our patient looked like he was in the ranks of the subjects in a study published in Sleep Breath in 2006,* which concluded that sleep apnea alone is a risk factor for an increased hematocrit.
Why are “too many red blood cells”—a condition called erythrocytosis—a bad thing? Because it usually means that there is a shortage of oxygen in the system and the body is creating more red blood cells to carry more oxygen to make up for the shortage. An elevated hematocrit is a risk marker for some very serious illnesses: heart disease, kidney disease and stroke. And less threatening but really unpleasant symptoms include pain, weakness, fatigue, headache, blurred vision and mental fuzziness.
That Sleep Breath study showed that as the average oxygen (O2) saturation dropped, hematocrit rose. The low-oxygen—hypoxic—environment created by sleep apnea is one possible mechanism for dropping O2 and elevating hematocrit. And as oxygen falls, your body has two main ways to compensate: (1) take in more air—not usually possible if you have sleep apnea; (2) make more red blood cells to carry more oxygen and/or concentrate the red blood cells by decreasing the other elements that make up your blood.
Over time, the body becomes more and more accustomed to low oxygen levels and the hematocrit stays elevated. Enter those very smart primary care physicians! In a patient with a consistently elevated hematocrit and other risk factors such as large neck circumference, high blood pressure, overweight and symptoms such as snoring and excessive daytime fatigue, it’s time for a sleep specialist to make an evaluation.
A sleep study will reveal if a patient is suffering from obstructive sleep Apnea (OSA) and decreased oxygen levels at night. One treatment for OSA is for the patient to use a continuous positive airway (CPAP) machine. CPAPs enable better airflow and oxygenation during sleep. A study published in Chest** showed that small group of patients treated with CPAP experienced significant decreases in hematocrit levels. A larger study from the European Respiratory Journal followed patients for over a year and demonstrated a similar decrease in hematocrit levels. ***
So what was going on with our patient who was using CPAP, but was excessively tired and unrested and had persistently elevated hematocrit? We put him on a program of optimized settings for his CPAP and a new mask better suited to him, combined with recommendations to be a “side-sleeper” not a back sleeper, to reach ideal body weight and to avoid alcohol around bedtime.
Results? We tested his blood levels again within 30 days of modifying his treatment, and his hematocrit tested normal, as did his hemoglobin. His red blood cells were just right!
Keep in mind, an elevated hematocrit does not necessarily mean you have sleep apnea. Nevertheless, over the years we have diagnosed and treated patients for OSA who have suffered at length with the effects of hypoxia because their health care providers did not consider a sleep disorder as the secondary source of their elevated hematocrit. So cheers for those perceptive and caring primary care physicians who get their patients with “too many red blood cells” evaluated for OSA!
Captain John Koch, MD, was recently a 4th-year medical student at Saint Louis University School of Medicine who engaged in a sleep and pulmonary specialty rotation with Dr. Ojile. Dr. Koch contributed greatly to the research and development of this review of elevated hematocrit and obstructive sleep apnea. We recognize his participation with gratitude.
* “Does obstructive sleep apnea increase hematocrit?” Jong Bae Choi, Jose S. Loredo, Daniel Norman, Paul J. Mills, Sonia Ancoli-Israel, Michael G. Ziegler, Joel E. Dimsdale; Sleep Breath (2006) 10: 155-160
** “Overnight Decrease in Hematocrit After Nasal CPAP Treatment in Patients with OSA,” Jean Krieger, M.D.; Emilia Sforza, M.D.; Mariette Barthelmebs, Ph.D.; Jean-Louis Imbs, M.D.; Daniel Kurtz, M.D.; CHEST, 97. 3 March 1990; pp 729-730
*** “Decrease in haematocrit with continuous positive airway pressure treatment in obstructive sleep apnoea patients” J. Krieger, E. Sforza, C. Delanoe, C. Petiau; European Respiratory Journal, 1992, 5, 228-233
11 Healthy New Year’s Resolutions You’ll Want to Steal
Most wellness professionals do a pretty good job of practicing what they preach, but truth be told, they’re still human. That means there’s always room for improvement! We asked 11 doctors, trainers and nutritionists to reveal their personal resolutions for 2015. From hydration changes to new workout inspiration, their goals will help them to be better versions of themselves. Follow these leaders and get ready for your healthiest year yet. (We won’t tell if you steal their resolution and make it your own!)
11 Healthy New Year’s Resolutions from the Pros
“My New Year’s health resolution: increased discipline on sleep, diet and exercise so that I can ski in the winter without getting injured and take a one-week vigorous cycling trip in the summer. I’m planning to exercise aerobically four or five days a week and do weight training twice a week. I’ll also reduce my total calorie and carbohydrate intake by 10 percent and get to bed by 10:30 pm six nights a week.”
Joseph M. Ojile, M.D., D.ABSM, F.CCP
Chief Executive Officer, Clayton Sleep Institute
There’s increasing real evidence—not just anecdotal– for the bio psychosocial relationship between stress, insomnia and depression, and the recurring, circular nature of these three unhealthy and unhappy states of mind and body. Not a shock for patients who suffer from insomnia or for the medical professionals who treat them, but important news in creating an environment to ramp-up research and treatment options for insomnia.
Our friend and colleague Chris Drake was lead investigator for an important research program on insomnia and stress that was published in the journal SLEEP* recently. Chris is Director of the Sleep Research Laboratory at Henry Ford Hospital, and a top-notch scientist. Chris’ research supports the likelihood of the link between insomnia and our reactions to, and perceptions of, ongoing stress.
In particular, Chris’ study looks at something new: how “cognitive intrusions” also seem connected to insomnia. Cognitive intrusions are those pesky, repetitive, unwanted thoughts about the stressful situation that you just can’t seem to turn off. In addition, the study reports that “sleep reactivity”—how likely your sleep will be affected negatively by stress—is also highly associated with insomnia. As the report notes, “Cognitive intrusion and sleep reactivity remained significant independent predictors of insomnia.”** Further, the study notes, “Our results suggest that sleep reactivity may represent a common vulnerability to both disorders [i.e., insomnia and depression], and further that insomnia mediates [i.e., brings about] the association between sleep reactivity and depression.”***
So stress and the inability to turn it off combine with sleep reactivity level to increase insomnia, which in turn leads to depression! And that, of course, means more stress. And less sleep. This is a cycle that “just keeps on going and going,” a lot like that battery-operated pink bunny, but not nearly as much fun.
No wonder insomnia is challenging for both patient and doctor!
Further, as Chris points out, “We’re still trying to answer the question, ‘What are the mechanisms by which insomnia evolves into depression.’ Once we determine these mechanisms we can target insomnia interventions much more effectively and efficiently.”
In the meantime, as a clinician who sees a lot of insomnia patients, I am enthusiastic about Chris’ and his team’s impressive, data-rich research. It fuels a deeper, richer investigation of insomnia and moves us closer to better ways to practice medicine to help insomnia patients. For my part, I see the prospect of the sleep medicine community moving toward clearer categories of insomnia and important examinations of the associations between insomnia and a range of psychiatric disorders.
One of my patients, a 56-year-old male who presented with “difficulty sleeping” is an illustrative case for the tie between psychiatric issues and insomnia.
My patient reported “years of inability to get sleep” as well as “lots of stress.” His primary issue was sleep initiation—being able to get to sleep. While the patient had bad sleep habits—sleep hygiene—that was not the only challenge. Discussion with him and his wife revealed that the patient was drinking “18 beers per night to help me get to sleep.” His wife also reported that the patient was irritable, frequently distracted and “gets frustrated easily.” She also reported that the patient snored.
This is definitely not-so-simple insomnia!
As we tested and further examined the patient, we determined he had undiagnosed anxiety disorder which he was self-medicating with alcohol. The patient was indeed an alcoholic, but in addition, a sleep study showed severe sleep apnea
We treated the patient with alcohol counseling and sleep behavior counseling, and prescribed antidepressants as well as a CPAP (continuous positive airway pressure) device for the sleep apnea. The outcome is that our patient experienced normalization of his anxiety and depression, his sleep improved markedly and consequently his daily life and functioning improved as well.
This is a case where it seems clear that long-term stress and anxiety caused chronic insomnia which led to ever-increasing levels of alcohol consumption, exacerbated by severe sleep apnea! But the hard truth is that we physicians and scientists do not really know how psychological and emotional states provoke insomnia, or how insomnia evolves into depression and other psychological disorders. And the more we know the larger our arsenal will be to help our patients combat insomnia.
There are exciting prospects before us, so stay tuned for more compelling data and treatment strategies in the battle against insomnia.
* “Stress and Sleep Reactivity: a Prospective Investigation of the Stress-Diathesis Model of Insomnia,” Christopher L. Drake, PhD; Vivek Pillai, PhD; Tomas Roth, PhD of the Sleep Disorders and Research Center, Henry Ford Hospital, Detroit, MI; Journal SLEEP, Vol. 37, No. 8, 2014
** Drake et. al., p. 1299
*** Drake et. al. p. 1302
It looks like sleep plays a key role in cognitive health for middle-aged and older adults. That may seem obvious to those of us who value sleep, but there is persuasive new information in a large multi-national study that as one reporter puts it, “…middle-aged or older people who get six to nine hours of sleep a night think better than those sleeping fewer or more hours.”1
The study was published in the June 2014 issue of the Journal of Clinical Sleep Medicine and was led by the University of Oregon (UO) and supported by the National Institute of Health and the World Health Organization. It is a very large study: 30,000 subjects in six middle-income nations in a project that began in 2007. That’s for both men and women, 50 years old or older in China, Ghana, India, Mexico and the Russian Federation.
Among the results reported in the JCSM article2 are,
- Individuals with intermediate sleep durations of 6-9 hours per night exhibited significantly higher cognitive scores than individuals with short sleep of 0-6 hours per night
- Men generally had higher sleep quality and cognitive scores while women reported longer sleep durations
- The study suggests that sleep measures may influence cognitive performance in older adults from different countries
Combine those observations with frequent reports that many older Americans experience an increase in the time it takes to fall asleep, a drop in the amount of REM sleep, an increase in fragmented sleep and insomnia 3 and we can see a need to get motivated for better sleep as we age!
It is never too soon or too late to check with your doctor about Obstructive Sleep Apnea (OSA), Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD). You may not hear much about RLS and PLMD, but as reported by the National Sleep Foundation, the prevalence for RLS increases with age—about 10% of people in North America and Europe report RLS symptoms, and 45% of all older persons have at least a mild type of PLMD.4
And don’t forget insomnia or the possible impacts on sleep from various medications!
Actively seeking the best possible, most consistent quality and quantity of sleep is as critical to our health and wellbeing throughout our lives, and clearly more and more important as we age. I am particularly taken by the comment from J. Josh Snodgrass, professor of anthropology at UO and a key investigator on SAGE (“Study on global AGEing and adult health”), “Every single piece of evidence that people look at now as they are investigating sleep and different health associations is all showing that sleep really, really, really matters.”5
I couldn’t agree more.
It’s no secret that there is a significant association between obstructive sleep apnea (OSA) and atrial fibrillation (AF), the most common type of heart arrhythmia. Both conditions are common, with over 2 million adults in the United States suffering from AF, and approximately one in 15 Americans with OSA. About 18 percent of U.S. patients with AF also have OSA.
Doctors also know that having OSA increases one’s risk for developing AF. In one Sleep Heart Health Study, patients with severe OSA had a four-fold increased risk for AF. This high risk is partially because OSA produces structural changes in the heart that can subsequently lead to AF.
Not only does OSA appear to be one cause of AF, the sleep disorder also creates complications for treating AF.
Studies have shown that untreated OSA decreases the likelihood of successful cardioversion1, the procedure (through prescription or electrical therapy) that can restore a fast or irregular heartbeat to a normal rhythm.
OSA also complicates the efficacy of radiofrequency catheter ablations2, the treatment used when medicines or cardioversion prove ineffective. Catheter ablations use radio waves transmitted through a wire inserted into the patient’s vein to destroy small areas of heart tissue where abnormal heartbeats may cause an arrhythmia. OSA also increases the risk for AF recurrence after catheter ablation.3
Patients with OSA and AF also show a 12 percent higher rate of hospitalizations than patients without OSA.
But that’s for untreated OSA.
New analysis shows that the proper OSA treatment can actually decrease the rate of progression of AF in patients.
During the annual 2014 meeting of the American College of Cardiology, Dr. Johnathan P. Piccini Sr. stated that patients who have OSA and AF and are treated with continuous positive airway pressure (CPAP) showed a 34 percent relative drop in the rate of AF progression.4
CPAP is in many cases the gold standard for treating OSA. A CPAP machine includes a mask to cover the nose or nose and mouth, a motor that blows air and a tube from the machine to the mask. When worn by the patient, the CPAP machine creates air pressure that prevents the airway from collapsing or becoming blocked during sleep. This results in continuous airflow to the lungs and oxygen-rich blood being delivered to the heart and the rest of the body.
“We know that if obstructive sleep apnea is treated (with CPAP), the AF burden can be dramatically reduced,” Piccini said.
If you’ve been diagnosed with or have received treatment for AF, talk to your doctor about scheduling a non-invasive at home or in-lab sleep study to determine if you are also suffering from a form of sleep apnea. The link between OSA and AF presents an important opportunity for potential CPAP treatment.
1. Dublin S, French B, Glazer NL, et al. Risk of new-onset atrial fibrillation in relation to body mass index. Arch Intern Med. 2006;166:2322-2328.
2. Jongnarangsin K, Chugh A, Good E, et al. Body mass index, obstructive sleep apnea, and outcomes of catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2008;19:668-672.
3. Naruse Y, Tada H, Satoh M, et al. Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following radiofrequency catheter ablation of atrial fibrillation: clinical impact of continuous positive airway pressure therapy. Heart Rhythm. 2012 Nov 22.
4. CHEST Physician Vol 9, No 5 May 2014 40-41