In our article on insomnia, we mention Singapore’s rank as one of the most sleep-deprived countries in the world. But do you know that our nation holds another title for snoring? Singapore has one of the highest sleep apnea incidents globally - a sleep disorder often associated with chronic snoring.
A study revealed that almost 1 in 3 Singaporean adults suffer from breathing difficulties due to sleep disorders, and more than half of them have moderate to severe sleep apnea syndrome. The condition is severely under-discussed and under-diagnosed, often being dismissed as just a snoring problem. In fact, when snoring disrupts the breathing pattern during sleep, it affects oxygen supply to the body and is a serious medical disorder. Health consequences range from daytime exhaustion and drowsiness to increased risks of serious diseases such as heart attack, stroke, hypertension, diabetes, dementia, and in severe cases even death during sleep.
In this article, we will discuss the complications of untreated sleep apnea, its signs and symptoms, how to differentiate between normal snoring and sleep apnea, and how to get diagnosed and treated if you suspect you or your loved one are suffering from it.
Table of Contents
1. What is Sleep Apnea?
Sleep apnea is a type of sleep disorder in which the breathing pattern is characterised by repeated pauses during sleep. People with sleep apnea stop breathing momentarily over and over again during the night, up to a few hundred times. As a result, their sleep cycle is frequently interrupted, preventing them from entering deep sleep, which is needed to feel refreshed in the morning. They often make choking and snorting noises in their sleep.
There are 3 types of sleep apnea.
- Obstructive Sleep Apnea (OSA): breathing interruption is caused by physical obstruction at the back of the throat, such as due to obesity or the physical characteristics of the person.
- Central Sleep Apnea (CSA): airway blockage is due to a problem with the portion of the brain controlling the muscles involved in breathing.
- Mixed Sleep Apnea: sleep apnea due to both physical obstruction and problems with the brain.
Obstructive sleep apnea (OSA) is by far the most common among the 3 types of sleep apnea. For this reason, obstructive sleep apnea is often referred to as sleep apnea. However, the type of sleep apnea a patient has needs to be diagnosed by the doctor.
2. Signs and Symptoms of Sleep Apnea
People with sleep apnea may stop breathing for 10 to 60 seconds during their sleep. When this happens repeatedly throughout the night, their blood oxygen drops significantly, sometimes to dangerous levels. Sleep quality suffers, which can lead to serious medical issues such as hypertension and diabetes, as mentioned in our article about health consequences of poor sleep quality here. Most noticeably, they often feel tired and sleepy the next day.
Below are the common signs and symptoms experienced by patients with sleep apnea:
- Frequently disrupted breathing throughout the night: During these disrupted moments, patients show signs of difficulty in breathing, choking, gasping or a stop in breathing altogether, for up to a minute. Patients themselves are often not aware of their breathing patterns during sleep and need to be told by others.
- Loud snoring with choking, gasping or snorting sounds that show trouble in breathing
- Frequent daytime drowsiness and fatigue despite logging a good number of sleeping hours
- Headaches in the morning after waking up
- Dry mouth or sore throat in the morning after waking up
- Difficulty concentrating and performing tasks at work or school
- Lack of interest due to constant lethargy
- Grumpiness due to prolonged fatigue
3. If I Snore Loudly, Do I Have Sleep Apnea?
Heavy snoring is one of the cardinal symptoms of sleep apnea. People who suffer from sleep apnea snore. However, not everyone who snores have sleep apnea. Up to 49% of adults and 40% of children are estimated to snore occasionally. Snoring can happen due to various reasons such as a cold, a sinusitis, an asthma, a deviated septum, or alcohol drinking. It is when snoring accompanies daytime sleepiness and fatigue that you should be concerned about sleep apnea.
The best way to recognise symptoms of sleep apnea is to monitor your activity and alertness during the day, and to have somebody observe your breathing during the night. If the observation reveals signs of breathing pauses during sleep, and you have constant difficulty concentrating during the day, fall asleep easily when driving, working, or studying, and generally feel tired, it is time to visit a doctor to check for sleep apnea.
One of the biggest issues regarding sleep apnea is its recognition, as many fail to differentiate between normal snoring and sleep apnea. In addition, many people are not aware that they snore if they sleep alone. This leads to under-diagnosis of the condition, until patients develop some serious disorders such as hepatic, cardiovascular diseases, or diabetes etc. It is therefore important to recognise the signs of sleep apnea, which will help with early diagnosis and treatment.
4. Causes & Risk Factors of Sleep Apnea
If you notice the signs and symptoms of sleep apnea above, and identify with the below risk factors, a trip to the doctor to check for sleep apnea is highly recommended.
Common causes and risk factors of sleep apnea include:
- Overweight and obesity: this is one of the leading causes of obstructive sleep apnea (OSA). Being overweight results in fat deposits in the upper airway area, making it narrower and causing breathing troubles during sleep.
- Small jaw and chin: this anatomical trait puts the upper airway and oral cavity at higher risk for being narrow and easily blocked.
- Nasal congestion: people who have chronic nasal congestion due to causes such as chronic sinusitis are at higher risk for sleep apnea.
- Family history: People with a close family member having sleep apnea are more likely to experience sleep apnea themselves.
- Alcohol consumption: As a sedative, alcohol can cause the throat muscle to over-relax and collapse, obstructing the airway. Similarly, using sedatives can have the same impact.
- Smoking: Smokers are twice more likely to develop sleep apnea compared to non-smokers, and heavy smokers are 7 times more likely, according to this study.
- Age: The chances of developing this sleep disorder increase with age. Elderlies are at higher risk of sleep apnea compared to younger adults.
- Gender: Different studies concluded that obstructive sleep apnea prevails more commonly in men compared to women and especially men with obesity.
- Others: Sleeping on the back increases the risk of sleep apnea, as this sleeping position causes the muscles around the upper airway to collapse more easily. Individuals with thicker necks are also more prone to having narrower upper airways.
Some of the above risk factors may explain the prevalence of sleep apnea in Singapore. We have an aging population, predominantly Asians with smaller jaw and chin, and a rising number of overweight and obesity cases. However, knowing the risk factors will also help us with prompt detection and treatment, preventing the potential serious health consequences as a result of untreated sleep apnea. Read on for complications of sleep apnea, and what you can do to address it.
5. What are the Health Consequences of Sleep Apnea?
Sleep apnea leads to fragmented and poor quality sleep, which has a negative impact on one's health, in particular heart health. The health effects of low-quality slumber have been detailed in our blog article here. With sleep apnea, the impact can be more serious and involve mental health, as the condition causes a distinct unhealthy sleep pattern, which we will explain in detail below.
Additionally, unlike people suffering from other types of sleep disorders, many sleep apnea patients are not aware of their condition. Some see the signs but do not make the connection between their daytime tiredness and sleepiness with their nighttime snoring - 2 of the most obvious signs of sleep apnea.. Others are not aware of their breathing patterns during sleep, or even how loudly they snore. The impact therefore can be accumulated for years before being identified and managed.
Following are the health complications that can result from sleep apnea. If you experience any of the complications, together with the signs and symptoms of sleep apnea mentioned above, it is crucial to discuss with a medical professional as quickly as possible to find out the primary causes and seek treatment.
5.1. Sleep Apnea & Cardiovascular Diseases
The frequent breathing pauses sleep apnea patients experience result in reduced blood oxygen levels, sometimes to critical levels. By now, most households in Singapore have had an oximeter to track our blood oxygen measurements. We know that the ideal blood oxygen level should be above 95%, and that we should seek medical assistance if it falls below 90%. Sleep apnea patients, however, frequently experience sub-optimal blood oxygen during their sleep, which can be as low as 60%, without knowing.
The repeated oxygen deficiency - known as hypoxemia - pushes the heart to work harder, instead of resting and healing as it should during sleep. When the heart is unable to provide sufficient oxygen, the brain perceives a danger and intervenes by waking up the body to quickly gasp for air. Thus, people with sleep apnea may wake up multiple times a night, despite looking like they are sleeping through. Hypoxemia can also lead to a systemic inflammation which has the potential to become persistent over time.
These harmful effects of the repeated sleep-wake cycle can lead to various cardiovascular disorders such as hypertension, stroke, heart attack, angina pectoris, and coronary heart failure.
- Hypertension: The constant pressure to increase heart rate and blood pressure to supply oxygen to the body during sleep can lead to long-term high blood pressure. 40-50% of people with sleep apnea are estimated to have high blood pressure. The good news is, when sleep apnea is treated, these individuals often also see improvement in their blood pressure.
- Heart diseases: Various studies show a strong correlation between sleep apnea and coronary artery disease such as cardiac arrhythmia (irregular heartbeat - atrial fibrillation being the most common), congestive heart failure (issues with the pumping function of the heart). Sleep apnea can increase the risk of heart failure by 140%. The cause is believed to be the irregular and often accelerated heartbeat that goes on every night among sleep apnea patients.
- Stroke: The risk of stroke increases by 60% in people with sleep apnea compared to those who do not have it. For this reason, patients with stroke are usually screened for sleep apnea as it is an under-recognized risk factor for stroke, putting them at higher risk for a recurrent stroke.
5.2. Sleep Apnea & Diabetes
Type 2 diabetes is common in patients suffering from sleep apnea. Scientists believe that metabolic changes due to sleep apnea causes insulin resistance, leading to diabetes. Insomniac stress also results in the active production of cortisol which is a contributing factor in altering metabolism. Furthermore, diabetes and sleep apnea share a number of major risk factors, such as being overweight, smoking, age and sedentary lifestyle. This contributes to the co-existence of sleep apnea and diabetes, which can exacerbate without proper treatment.
5.3. Sleep Apnea & Dementia, Alzheimer’s disease
Multiple studies have found evidence of linkage between obstructive sleep apnea and Alzheimer’s disease and other types of dementia. Recent research establishes that severe OSA increases the chance of developing a protein called beta-amyloid. The amyloid plaques that build up from this protein cause damages in the brain, leading to dementia.
Comorbidity again contributes to the linkage between the two conditions. Elderly adults are usually lighter sleepers, with higher incidence of insomnia. They also have a greater chance of developing Alzheimer's as well as dementia. In individuals with existing dementia, having sleep apnea can make it worse.
5.4. Sleep Apnea & Kidney Diseases
According to a 10-year study, people with sleep apnea are 58% more likely to develop kidney diseases compared to those without. Another research points out that sleep apnea is more prevalent among end-stage renal disease (ESRD).
Coupled with the fact that hypertension and diabetes are leading risk factors for kidney diseases, the coexistence of sleep apnea and kidney diseases is not surprising. Though linked, treatment for the two conditions needs to be taken care of simultaneously yet independently. To learn more about the prevalence of kidney diseases in Singapore, read our article about common kidney conditions and how diabetes and hypertension can cause kidney diseases here.
5.5. Sleep Apnea & Mental Health
The quality of sleep has a great impact on your productivity and routine the next day. People with sleep apnea wake up from their night slumber without getting the benefits of a restful sleep. They are often irritable, moody, drowsy and anxious, after going through repeated cycles of sleep-wake the night before. Because of the fragmented sleep, sleep apnea patients also experience difficulty concentrating. They are at a high risk of causing accidents when driving, and general reduction in productivity at work or school, putting them at further stress day in day out.
Prolonged sleep apnea without treatment is associated with mental health problems, such as depression, anxiety, post-traumatic stress disorder (PTSD) and in some cases, psychosis and schizophrenia. The mechanism of how it happens is complex and is believed to involve the inflammatory response of the body during the breathing pauses experienced by sleep apnea patients. Even when sleep apnea patients are not clinically diagnosed with mental health issues, it is clear that they suffer a great deal in terms of their psychological well-being.
6. Diagnosis of Sleep Apnea
Diagnosis of sleep apnea is often carried out by your GP or family doctor and a sleep specialist. The GP assesses your symptoms, reviews your medical history and risk factors. The sleep specialist comes in to evaluate the type and severity of sleep apnea, through a series of sleep studies. These tests provide the doctor with your vital signs during sleep, including heart rate and blood oxygen fluctuations during the night.
One of the tests is called a polysomnogram. It requires the patient to stay overnight at a sleep clinic or hospital. The test monitors the performance of all the organs commonly affected during sleep apnea such as brain waves, eye movements, muscle activity, heart rate and rhythm, abnormality in oxygen level, and analysis of artery walls. Sleep apnea screening at home may also be possible, using personal ECG monitoring devices such as RootiRx.
With the results from the sleep study, the doctors determine the severity of sleep apnea and treatment plan, taking into consideration other coexisting conditions, whether the patient is an elder or younger adult, medications they are taking for other conditions, etc.
7. Treatment and Therapies of Sleep Apnea
The goal of treating sleep apnea patients is to unblock the airway and allow for sufficient air supply into the lungs. The following treatment and therapies are commonly prescribed, though it differs from one individual to another.
7.1. Losing Weight
Among sleep apnea patients who are overweight, this is often the first action doctors recommend to patients. This is a major risk factor, but also a modifiable one. Without weight control, a 10% increase in weight can lead to 6 times higher risk of developing moderate-to-severe sleeping disorder breathing. After losing weight, most patients report improvement in quality of sleep.
7.2. Lifestyle Changes
- Engaging in physical activities: Sleep apnea leads to daytime tiredness, reducing the desire and endurance to engage in physical activities. This further worsens the symptoms of sleep apnea and other comorbidities, in a vicious circle. Exercising helps to break the cycle and promote better sleep, especially among elderly patients who tend to be less active.
- Quitting drinking: Since alcohol increases snoring and the likelihood of sleep apnea, patients are recommended to reduce alcohol consumption as much as possible:
- Quitting smoking: Smoking is the common risk factor for sleep apnea as well as many of its serious comorbid conditions such as high blood pressure and diabetes. Quitting smoking therefore is recommended to improve sleep apnea and the patient’s general health condition.
- Sleeping on the side: Sleeping on one’s back is more likely to cause sleep apnea than on the side. Thus, sleep apnea patients are encouraged to switch to sleeping on the side to improve the symptoms.
7.3. Nasal Decongestants
If patients suffer from airway blockage due to a chronic nasal congestion, a consultation and treatment with an ENT doctor is recommended to treat the nasal condition. Nasal decongestants can also be used for temporary relief.
7.4. Positive Airway Pressure (PAP) Therapy:
PAP therapy uses a device to improve the breathing mechanism for sleep apnea patients who do not see improvements with other therapies. There are 2 types of PAP therapies:
- Continuous positive airway pressure (CPAP), primarily recommended for obstructive sleep apnea (OSA)
- Bi-level positive airway pressure (BiPAP), most often recommended for central sleep apnea (CSA) or those with OSA who are not suitable for CPAP.
In both CPAP and BiPAP, the patient is required to wear a facemask during sleep. The mask is hooked to a portable machine that gently pumps compressed air to the patient’s airway to keep it open, allowing the patient to sleep and breathe comfortably. The difference between CPAP and BiPAP is in their pressure settings. CPAP uses 1 pressure for both inhalation and exhalation while BiPAP uses 2 different settings - one for inhalation positive airway pressure (IPAP) and one for exhalation positive airway pressure (EPAP). The other difference lies in their costs. BiPAP is more costly. In Singapore, CPAP can cost SGD 2,000 or more, while BiPAP can cost SGD 4,000 or more.
The disadvantage of PAP therapy is comfort and discipline. While it undeniably improves sleep quality for people with sleep apnea, some find it troublesome and uncomfortable to wear during sleep. Others may not adhere to strict nightly usage, thus not realising the benefits of the therapy during treatment.
7.5. Oral appliances to expand the upper airway
Patients who have small jaw lines and find PAP devices cumbersome may benefit from oral or dental appliances that can be worn at night to help reposition the jaw and tongue during sleep, relieving airway blockage. Though smaller, these appliances can also be quite costly, and need to fit well with the patients.
7.6. Surgery
When all the above first-line therapies are not effective, surgery is advised to patients to help remove blockage. A procedure called uvulopalatopharyngoplasty (UPPP) is performed to remove the extra tissues in the throat area and expand the airway for the patient. In Singapore, UPPP can cost SGD 10,000 or more, depending on the individual.
8. Takeaway Message
Snoring might be common, even a fun fact to joke about. However, when snoring is caused by sleep apnea, it is a serious health problem that needs to be addressed by medical specialists. We hope the article raises awareness for the various consequences of sleep apnea and why it should not be dismissed as just a snoring problem. By providing you with specific ways to differentiate between normal snoring and sleep apnea, we hope to help you quickly recognise sleep apnea in yourself or your loved one if it exists. Sleep apnea is treatable and its consequences are preventable with prompt treatment and lifestyle changes.
At Ninkatec, we provide medical consultation at home to patients with sleep disorders like sleep apnea. Your comfort and well-being is our priority. Consultation with doctors can be done in the comfort of your home, with house call doctors visiting you at home, or tele-consultation via video call. Sleep and heart rate can also be monitored at home for your convenience, using advanced monitoring technology.
Contact Ninkatec Care Team for a personal consultation regarding your snoring or sleep apnea problem via call, WhatsApp, email or leave us a message in the below form. Our GP partners also offer the same service in-clinic at below clinic locations across the island:
- A Life Clinic Pte Ltd – Dr Choo Kay Wee
- Hwang & Liang Family Clinic & Surgery – Dr Lim Shee Lai
- Charazoi Medical Clinic – Dr Choo Dee Pheng
