Obstructive Sleep Apnea (Not so) Sweet Dreams

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1 Obstructive Sleep Apnea (Not so) Sweet Dreams Sleep, riches, and health, to be truly enjoyed, must be interrupted. -- Jean-Paul Richter Presented by: Brad Heltemes, M.D. VP & Chief Medical Director ING For agent use only. Not for public distribution Disclosures Neither ING or its affiliated companies or representatives offer legal or tax advice. Consult with your tax and legal advisors regarding your individual situation. Life insurance products are issued by ReliaStar Life Insurance Company (Minneapolis, MN), ReliaStar Life Insurance Company of New York (Woodbury, NY) and Security Life of Denver Insurance Company (Denver, CO). Variable universal life insurance products are distributed by ING America Equities, Inc. Within the state of New York, only ReliaStar Life Insurance Company of New York is admitted and it's products issued. All are members of the ING family of companies All guarantees are based on the financial strength and claims paying ability of the issuing insurance company, who is solely responsible for all obligations under its policies. Before investing, your clients should carefully consider their need for life insurance coverage and the charges and expenses of the variable universal life insurance policy. They should also consider the investment objectives, risks, fees, and charges of each underlying variable investment option. This and other information is contained in the prospectuses for the variable universal life insurance policy and the underlying variable investment options. Clients may obtain these prospectuses from you, by calling , or from and should read them carefully before investing. For agent use only. Not for public distribution 2

2 Sleep APNEA Syndrome From the Greek: a- non pnea- breathing More precisely, want of breath Definitions Apnea Cessation of airflow. It exists when airflow is less than 20% of baseline for at least ten seconds in adults. Three types of apnea may be observed during sleep: Obstructive apnea airflow is absent or nearly absent, but ventilatory effort persists. It is caused by complete, or near complete, upper airway obstruction. Central apnea occurs when both airflow and ventilatory effort are absent. Mixed apnea an interval during which there are both patterns, the central apnea pattern usually preceding the obstructive pattern. Hypopnea A reduction of airflow to a degree that is insufficient to meet the criteria for an apnea. Airflow decreases at least 30% from baseline and there is diminished airflow lasting at least ten seconds Respiratory effort related arousals A sequence of breaths that lasts at least ten seconds, is characterized by increasing respiratory effort and leads to an arousal from sleep, but does not meet criteria of an apnea or hypopnea (previously called "upper airway resistance syndrome ) Desaturation Decline in oxygen saturation of > 4% Arousal index Total number of arousals per hour of sleep

3 Obstructive Sleep Apnea-Hypopnea (OSAH) Obstructive sleep apnea-hypopnea is defined as either: More than 15 apneas, hypopneas, or RERAs per hour of sleep (i.e. an AHI or RDI >15 events/hr) in an asymptomatic patient, OR More than five apneas, hypopneas, or RERAs per hour of sleep (i.e. an AHI or RDI >5 events per hour) in a patient with symptoms (e.g. sleepiness, fatigue and inattention) or signs of disturbed sleep (e.g. snoring, restless sleep, and respiratory pauses). More than 75 percent of the apneas or hypopneas must have an obstructive pattern Epidemiology Thought to be rare prior to 1970 yet now estimated 31% of men and 21% of women at high risk for OSAH Random sample of 602 employed persons age 30 to 60 given polysomnograms. 24% of men and 9% of women with AHI > 5 (9% and 4% with AHI >15) Estimated 6-9% of men and 3-4% of women with OSAH (AHI > 5 plus daytime sleepiness) Values increased with age, leveling off at age 65

4 Mechanics of Obstructive Sleep Apnea Pharyngeal crowding Decreased muscle tone during sleep Apneas and Hypopneas Oxygen desaturation, cyclical HR variation, failure of BP to decrease, arousal Underwriting OSAH 1. Identifying its presence 2. Gauging its severity 3. Assessing the treatment and outcome

5 Predicting OSAH Symptoms Signs Risks Apneas, Excessive Daytime Sleepiness (EDS), Snoring Obesity, Airway crowding, Hypertension Age more than twice as common at age >65 than if Gender 2-3 times more common in men, for ages <60 Smoking three-fold risk Heredity 2-4x increased, beyond the affect of the above Chronic nasal congestion risk increased 2x regardless of cause Diabetes risk 3x that of general population Predicting OSAH Likelihood of significant OSAH (defined as AHI >15) is approximately: 50% if one is referred for a sleep study 75% if has EDS plus at least four of the previously noted signs, symptoms, or risks >90% if the above, plus an overnight oximetry test showing RDI >10

6 Assessing Severity of OSAH Apneas, hypopneas, and arousals Mild: AHI of 5-15 Moderate: AHI of Severe AHI >30 or O 2 saturation <90% for >20% of the time Oxygen saturation during sleep O 2 sat <80%, or <90% for 5 minutes or more Measures of excessive daytime sleepiness (EDS) Assessing Severity of OSAH Apneas, hypopneas, and arousals Oxygen saturation during sleep Measures of excessive daytime sleepiness (EDS)

7 Excessive Daytime Sleepiness (EDS) Subjective complaints Fatigue Falling asleep inappropriately Frequent napping Objective measures Epworth Sleepiness Scale (ESS) Multiple Sleep Latency Test (MSLT) Maintenance of Wakefulness Test (MWT) EDS and Accident Risk Those with AHI >15 were 7.3 times more likely to have had multiple serious accidents Despite the cost of treatment for OSAH, estimated that treating all with OSAH would save $8 billion and 980 lives annually MVA mortality risk may be as great as the excess CAD risk from OSAH Risk appears to correlate more with degree of sleepiness than with AHI

8 Assessing Severity of OSAH Apneas, hypopneas, and arousals Oxygen saturation during sleep Measures of excessive daytime sleepiness (EDS) Diagnosing OSAH The Polysomnogram (PSG)

9 Abbreviations in Sleep Medicine OSAH - Obstructive Sleep Apnea- Hypopnea OSA - Obstructive Sleep Apnea OSAS - OSA Syndrome CSA Central Sleep Apnea SAS - Sleep Apnea Syndrome SAHS - Sleep Apnea-Hypopnea Syndrome UARS - Upper Airway Resistance Syndrome OHS - Obesity-Hypoventilation Syndrome SRBD - Sleep-Related Breathing Disorder PSG - Polysomnogram AI - Apnea Index AHI - Apnea-Hypopnea Index RERA - Respiratory Effort-Related Arousal RDI - Respiratory Disturbance Index ODI - Oxygen Desaturation Index O2 Sat / SaO2 - Oxygen Saturation % EDS - Excessive Daytime Sleepiness ESS - Epworth Sleepiness Scale MSLT - Multiple Sleep Latency Test MWT Maintenance of Wakefulness Test CPAP - Continuous Positive Airway Pressure BPAP - Bilevel PAP APAP Autotitrating PAP UPPP - Uvulopalatopharyngeoplasty Polysomnogram (Sleep Study) Diagnosis = AHI/RDI >5 per hour Oxygen desaturations Sleep Latency Alterations of sleep architecture Other causes of arousals

10 OSAH Severity Measures AHI O2 Sat EDS Low Time <90% ESS Sxs MILD 5-15 > 85% < 5% <8 Minor MODERATE % 5-20% 8-12 Adjusted schedule SEVERE > 30 < 75% > 20% >12 Inappropriate times Consequences of OSAH 1. Cardiovascular risk 1. CAD, CVA, Pulmonary HTN 2. HTN 3. Sudden death 2. Decreased neurocognitive function 1. Decreased reaction time 2. Irritability, personality changes 3. Confusion, intellectual impairment 3. Accidents

11 Treatment of OSA Weight loss, sleep position therapy, safety measures, EtOH avoidance Mild disease Oral appliances Surgical treatment Usually UPPP or variant. Also Tonsillectomy &/or Partial glossectomy at times. Bariatric surgery Tracheostomy Pharmacologic therapy for EDS - Modafinil (Provigil) CPAP, BiPAP, APAP Treatment of OSA - CPAP Only CPAP and Tracheostomy have been shown to reduce mortality CPAP - Continuous Positive Airway Pressure BiPAP - Bilevel Positive Airway Pressure Functions as an airway splint Use shown to improve daytime sleepiness, snoring, mood, and cognitive function, and to reduce accidents, BP, and mortality. Back to normal???

12 Sleep Apnea Case #1 51 y.o. male, #; $390,000 Sleep study done 3 months prior to application

13 Case #1 (cont.) 51 y.o. male; sleep study 3 mos ago RDI: 89.2 Low O2 sat: 89% Percent time O2 sat <90%: 1.8 mins out of 317 total = 0.6% Sleep Apnea severity? Overall consider as moderate Likelihood of long-term CPAP compliance? Mortality risk? CPAP Compliance Generally considered as > 6 hrs/night Of those who try CPAP, roughly ½ will not be using it one year later Predictors of continual use: Adherence for the first month Worse sleep apnea related symptoms Self reported use, even to one s own doctor is not very reliable Regular follow-up and prescriptions for CPAP equipment suggest ongoing use CPAP machine meter recordings are most accurate

14 Mortality Risk of OSA Cohort study of 871 patients with OSAH, average age 55, average AHI 55 Campos-Rodriguez, et al year mortality based on CPAP use: 4.6% CPAP >6 hrs/day 8.7% CPAP 1-6 hrs/day 14.5% CPAP <1 hr/day Other independent mortality risk included HTN and Low FEV1 Mortality Risk of OSA Those with untreated severe OSA have 3-6 times increased all-cause mortality Less so for moderate disease and probably little or none in mild Likely age dependent: Prospective study, 1620 pts, 90% male Lavie, et al 1995 Re-analysis attempting to adjust for variables: Age 20-39: +330% Age 40-49: +70% Age 50-79: +0%

15 Case #1 (cont.) 51 y.o. male; sleep study 3 mos ago RDI: 89.2, low O 2 sat 89%, percent time with O 2 sat <90% 0.6% Sleep Apnea severity? Moderate Mortality risk? Depends heavily on CPAP compliance; likely low substandard if compliant at 3 months but otherwise moderate substd Sleep Apnea Case #2 67 y.o. male; $1,000,000 UL 6 0, 219 lbs, NS, BP 128/88 APS: Sleep apnea dx 2006, 181 apneas CPAP Tx; renewals 2009, : Denies daytime sleepiness Hx of HTN, fam hx CVA and CHF, chest pain hx - cath normal Sleep apnea? Severity/Treatment/Age? Enough info to assess?

16 Case #2 67 y.o. male; 6 0, 219 lbs, NS, BP 128/88 APS: Sleep apnea dx 2006, 181 apneas CPAP Tx; renewals 2009, Denied EDS. Hx of HTN, fam hx CVA and CHF, cath normal Sleep apnea? Estimated AHI around 30 Added risks CAD risks (but normal cath) Severity/Treatment/Age? Moderate but no O2 Sat or EDS info Mortality Risk? OSA in Older Individuals Lavie: Age >50 SMR 1.0 He, et al: >age 50 SMR 1.7 (uncorrected) Ancoli-Israel: Mean age 72.5 SMR of 1.6, but +0 after corrected for other factors Mant: Age 80 No affect on survival

17 Case #2 67 y.o. male; 6 0, 219 lbs, BP 128/88 Sleep apnea? Estimated AHI around 30 No CAD Severity/Treatment/Age???Moderate CPAP Tx; renewals 2009, likely on CPAP Age 67 Excess Mortality Risk? Little or none Sleep Apnea Case #3 40 y.o. male; $300,000 Term lbs, NS, BP 130/80, lab all WNL App: HTN, OSAH 2008 resolved with surgery Any mortality risk? APS needed?

18 Case #3 Sleep study 8/07 Obstructive sleep apnea? AHI 34.5, Low SaO2 of 80%, 9% of time <90% Severity? Anything missing? Epworth Sleepiness Score of 15 Moderately severe OSA Mortality Risk post surgery? Case #3 12/07: Unable to sleep with nasal CPAP 1/08: UPPP and septoplasty 2/08: Decreased snoring, more restful sleep 11/10: DOE, HTN, OSA. ECHO Normal except mild LVH 6/11: Doing well following UPPP until recently, now snoring and interrupted sleep again. Has gained lbs. 5 7, 213 lbs. 8/11: Will try CPAP or if not tolerated, oral appliance. LOV.

19 Case #3 Obstructive sleep apnea still present? Most likely Severity/Treatment/Age? Unable to fully gauge severity, possibly some better but also tends to worsen with age and increasing weight UPPP probably not successful, no indication of other Tx Mortality Risk? UPPP for OSA Little long-term data Roughly 50% will experience an RDI improvement of > 50% However at least half of these will develop recurrence of significant OSAH after 2 yrs Improvement in EDS correlates somewhat with response but snoring improvement does not Few credits for UPPP warranted unless has had f/u sleep study, more than two years after the procedure, showing good results

20 Sleep Apnea Case #4 30 y.o. male, $700,000 Term 6 2, 183 lbs, Smoker, BP 102/60 3/07: Wife concerned about severe snoring and breathing badly at night. Fatigued during the day. Sleep study advised. No f/u since. Does he have sleep apnea syndrome? Mortality risk? Predicting OSAH Likelihood of significant OSAH (defined as AHI >15) is approximately: 50% if one is referred for a sleep study 75% if has EDS plus at least four of the previously noted signs, symptoms, or risks >90% if the above, plus an overnight oximetry test showing RDI >10

21 Case #4 (cont.) 30 y.o. male, 6 2, 183#, BP 102/60 3/02: Wife concerned about severe snoring and breathing badly at night. Fatigued during the day. Sleep study advised. No f/u since. Findings for and against OSAS? For: Sxs x 3, smoker. Against: Build, age (and BP?) Mortality risk? High if has OSAHS but likelihood probably no more than 50% Underwriting Assessment of OSAH Severity AHI O 2 Saturation EDS Treatment CPAP Titration study to assess benefit, often no f/u study beyond that if stable Oral device, UPPP, Wt loss F/u study Sleep position therapy mild OSA only Age Greatest risk < 40, possibly little >65

22 Underwriting OSA Untreated, unselected, baseline mortality probably ~2-3X expected Especially high with severe disease and at younger ages May be little at older ages Severity gauged not just by AHI but also by low O2 sat and/or time with Sa O2 <90%, and by degree of daytime sleepiness. Verification of CPAP compliance is critical Beware HTN, CAD, Dysrhythmias, CVA, Pulm HTN, COPD, MVA hx, EtOH. Living is a disease from which sleep gives us relief eight hours a day. -- S. R. N. Chamfort

23 Simple diagnosis of OSA Syndrome You're too fat, too much bread. Your wife's afraid you'll soon drop dead. Cause in your sleep, she doth perceive, That when you doze you do not breathe. Bibliography 1. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Marshall NS, et al. Sleep. 2008;31(8): Sleep-disordered breathing and mortality: a prospective cohort study.punjabi NM, et al. PLoS Med. 2009;6(8). 3. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. Young T, et al. WMJ. 2009;108(5): Continuous positive airways pressure for obstructive sleep apnoea in adults. Giles TL, et al. Cochrane Database Syst Rev. 2006;3. 5. Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis. Greenburg DL, Lettieri CJ, Eliasson AH. Am J Med. 2009;122(6): Mortality and apnea index in obstructive sleep apnea. Experience in 385 male patients. He J, et al. Chest. 1988;94(1):9. 7. Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure. Campos-Rodriguez F, et al. Chest. 2005;128(2): Uvulopalatopharyngoplasty in the management of obstructive sleep apnea: the mayo clinic experience. Khan A, et al. Mayo Clin Proc. 2009;84(9): ING North America Insurance Corporation