Obstructive Sleep Apnea and Its Health-Related Complications
Release Date: January 1, 2016
Expiration Date: January 31, 2018
Yvette C. Terrie, BS Pharm, RPh
Clinical Pharmacist/Freelance Medical Writer
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Dr. Terrie has no actual or potential conflicts of interest in relation to this activity.
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To provide pharmacists with a review of the etiology and pathophysiology of obstructive sleep apnea, its health related consequences, risk factors, and currently available treatment options.
After completing this activity, the participant should be able to:
- Review the causes and consequences of untreated obstructive sleep apnea.
- Identify the risks factors and signs and symptoms associated with obstructive sleep apnea.
- Understand the various treatment strategies for managing obstructive sleep apnea.
- Acknowledge the role of the pharmacist in identifying and managing patients with obstructive sleep apnea.
ABSTRACT: Obstructive sleep apnea (OSA) is a sleep disorder characterized by pauses in breathing during sleep. Left untreated, OSA is associated with a series of serious health complications including decreased daytime alertness, reduced quality of life, cognitive impairment, cardiovascular and neurologic morbidities, and eventually premature death. The standard treatment is continuous positive airway pressure (CPAP), which has been shown to reduce or reverse some of the unwanted effects associated with undiagnosed or untreated sleep apnea. Other treatment options available for OSA include the use of oral appliances, weight loss, sleep hygiene, surgical procedures, and pharmacologic agents for residual sleepiness.
In our fast paced world, many individuals are sleep deprived of their own volition, electing to stay up late instead of getting an adequate amount of sleep each night; however, there is another part of the population that is sleep deprived and many are not even aware of it due to a serious medical condition known as obstructive sleep apnea (OSA). This sleep disorder was first recognized in 1965 and is characterized by the recurring collapse of the pharyngeal airway leading to restricted airflow during sleep.1-3 When someone has OSA, complete collapse of the airway results in apneic episodes (suspension of breathing), while partial collapse leads to hypopneic episodes (slow, shallow breathing).4
Apnea is defined by the American Academy of Sleep Medicine as the cessation of airflow for at least 10 seconds.5 In general, patients with OSA may experience pauses in breathing that can range from 5 to 30 seconds, but sometimes pauses may last a minute or longer and can occur from 5 to as many as 100 times a night.5
Sleep apnea manifests itself in two forms: OSA, in which throat muscles relax and enough air cannot flow into the lungs through the mouth and nose, and central sleep apnea (CSA), which occurs when the brain does not send the correct signals to the muscles that control breathing.6 OSA is the most common form of sleep apnea, affecting an estimated 9 out of 10 patients with sleep apnea.6 This article will focus on OSA, its risk factors, signs and symptoms, health conse quences, and treatment.
Risks of Untreated Sleep Apnea
Left undiagnosed or untreated, OSA can lead to a plethora of adverse health consequences including an increased incidence of hypertension, stroke, myocardial infarction, heart failure, coronary artery disease, cardiac rhythm problems, insulin resistance, type 2 diabetes, gastroesophageal reflux disease (GERD), nocturnal angina, hypothyroidism, neurocognitive difficulties, and mortality.1,5,7,8 Clinical studies have demonstrated that effectively treating OSA may improve and control hypertension and diminish the risk of cardiovascular complications.9
OSA often causes or exacerbates several comorbid conditions. The critical nature of treating OSA and related comorbid conditions in various neurologic disorders has sparked immense interest among researchers and has been increasingly gaining more recognition among healthcare professionals.10 The incidence of OSA is more frequent in neurologic patients, affecting at least one-third of those with epilepsy and an estimated two-thirds of stroke survivors.8 Currently, sleep-disordered breathing such as OSA is quite common in patients with neurologic conditions, and there are a host of neurologic disorders that clinical studies have demonstrated are improved by treating the underlying comorbid sleep apnea, including dementia, stroke, headache, and epilepsy.10,11 There is now growing evidence that treating OSA in patients with certain neurologic issues may also improve neurologic outcomes such as cognitive functioning and seizure control.9,12
Some researchers estimate that the number of individuals with OSA is comparable to the number who are diagnosed with diabetes or asthma.6 Unfortunately, since OSA patients are often unaware of the condition, OSA frequently goes unrecognized or undiagnosed until another individual witnesses the patient having episodes of chronic snoring, choking, gasping for air or pauses in breathing during sleep, or when the patient seeks medical care due to complaints of chronic daytime sleepiness or other OSA symptoms. Various clinical studies have revealed that untreated OSA is associated with decreased quality of life, significant functional impairment, and increased risk of road traffic accidents; sleep apnea is also a leading cause of excessive daytime sleepiness.13,14 Results from a recent study conducted by Karimi et al reported that individuals with untreated OSA are 2.5 times more likely to be involved in a motor vehicle accident compared with the general population because of impaired driving performance and fatigue.15 Results from an observational study found that women with untreated severe OSA are 3.5 times more likely to die of cardiovascular disease than women without OSA.16
The World Health Organization estimates that 100 million people worldwide have OSA.17 According to the National Healthy Sleep Awareness Project, the number of OSA cases is continually escalating, affecting an estimated 25 million adults in the United States.18,19 Statistics report that moderate cases of OSA disease are now apparent in 17% of middle-aged men and 9% of women.18,19 Unfortunately, statistics also report that <25% of individuals with OSA have been diagnosed, and a significant portion of the American population are not even aware that they have OSA or are at risk for this serious medical condition.20
Clinical data from a study conducted by Peppard et al reveals that the estimated incidence of OSA has increased drastically over the last 20 years due to the continuing obesity epidemic in this country.19,21 Statistics estimate that 26% of adults between the ages of 30 and 70 years have some degree of OSA.19 These new data undoubtedly reveal that healthcare professionals should seize every opportunity to increase awareness about the signs and symptoms of OSA as well as the grave healthcare consequences associated with untreated OSA.
Etiology and Pathophysiology
While the exact cause of OSA is not entirely understood, research suggests that it is possibly due to the interaction between unfavorable anatomic upper airway susceptibility and sleep-related changes in upper airway function.22 OSA is further characterized by a recurrent collapse of the velopharyngeal and/or oropharyngeal airway during sleep, resulting in substantially reduced or complete cessation of airflow despite ongoing breathing efforts.23 This causes intermittent disturbances in gas exchange such as hypercapnia (excessive carbon dioxide in the bloodstream), hypoxemia, and fragmented sleep.23 While upper airway collapse can occur during both rapid eye movement (REM) sleep and non-REM sleep, decreased genioglossus muscle tone during REM sleep significantly increases the tendency for upper airway obstruction.23 As a result, the severity of OSA in REM sleep is higher in some individuals, and there is some indication that REM-predominant sleep apnea may exacerbate the adverse cardiovascular and metabolic effects often linked to OSA.23
Risk Factors: The pathophysiology of OSA can be related to both structural (anatomic) and nonstructural factors.23 Examples of risk factors for OSA can be found in TABLE 1.5,24-28
The most studied and well-known risk factor for OSA is obesity.27 Studies report that an estimated 70% of patients with OSA are obese, and an estimated 40% of obese individuals have OSA.28 Moreover, an estimated 60% of OSA patients also have metabolic syndrome, but it is important to remember that individuals with normal or even low body mass indexes (BMIs) may develop OSA as well.28 Since familial history of OSA is present in an estimated 25% to 40% of OSA cases, there is also a possible genetic link.5,24,26
Clinical Presentation and Diagnosis of OSA
Initially, OSA symptoms present in a gradual and subtle manner. Patients often are unaware that they have OSA for years before being referred for evaluation or presenting with complaints or symptoms.25 The majority of patients with OSA first come to the notice of a clinician because the patient reports extreme daytime fatigue or after a loved one reports witnessing episodes of loud snoring, gasping, snorting, or interruptions in breathing while the patient is sleeping.5,24 Episodes of chronic snoring are often considered the hallmark symptom associated with OSA. But while loud disruptive snoring is reported in an estimated 85% of OSA patients, it is important to note that not everyone who snores has OSA.24 Examples of other classic OSA signs and symptoms include episodes of choking or gasping for breath and pauses in breathing during sleep (TABLE 2).5,24
These symptoms may be brought to the attention of a healthcare provider when noticeable, reported during the evaluation of another health issue, identified during a routine physical examination, or reported during preoperative screening.29 Regardless of how the symptoms are identified, clinicians should screen all patients who report or exhibit classic OSA symptoms and examine them for other features or risk factors related to OSA. This medical information is vital for determining which patients require further diagnostic testing.29
Patients with OSA may also present with episodes of nocturia and may complain of trouble staying asleep.24,30 While awake, OSA patients may experience hypersomnolence, chronic fatigue, lack of energy, unintentional sleep episodes, morning headaches, irregular heartbeat, chronic elevation in daytime blood pressure, xerostomia upon waking, impaired concentration, mood swings, anxiety, panic attacks, or depression, as well as decline in quality of life that may negatively impact social, familial, and professional performance.5,24,31
Some studies indicate that females often present with slightly atypical or unusual symptoms, and OSA may often go undiagnosed secondary to these.32,33 Instead, OSA experts report that some women may present with symptoms such as general feeling of malaise, insomnia, difficulty falling asleep or staying asleep, panic attacks, anxiety, or mood changes that may suggest other medical issues besides OSA.32,33
Some women with OSA may have more subtle breathing disturbances and are more likely to have REM-related apneas.32,33 Results from a clinical study revealed that women with sleep apnea often appear healthy and have subtle or understated symptoms and, as a result, are often misdiagnosed or go undiagnosed until health complications occur.33
A diagnosis of OSA is normally based upon evaluating medical and family history, risk factors, patient symptoms, physical examination, and results from the polysomnography (PSG) test, also known as a sleep study, if warranted.5,24 The PSG test involves a continuous measurement of breathing effort via plethysmography, airflow at the nose and mouth via flow sensors, oxygen saturation by oximetry, sleep architecture by electroencephalography (EEG), chin electromyography (looking for hypotonia), and electro-oculography to evaluate the occurrence of REMs.5,24 Additionally, PSG monitors and helps classify the stages of sleep and the incidence and duration of apneic and hypopneic periods.5,24
OSA can be classified as mild, moderate, or severe based upon the apnea-hypopnea index (AHI), which is the number of apneas and hypopneas per hour of sleep.5,24 An AHI >5 is required for a diagnosis of mild OSA, >15 indicates moderate OSA, and >30 shows severe OSA.24,34,35 Since the symptoms of OSA are not highly specific, it is imperative that clinicians rule out other conditions that may cause excessive daytime sleepiness, such as narcolepsy, and other disorders, such as panic attacks, pulmonary disease, and GERD, which can also hinder or affect sleep.28
According to the American Sleep Apnea Association, patients who suspect that they may have OSA may also use the organization’s self-test questionnaires such as the Snore Score, the Epworth Sleepiness Scale, and the Berlin Sleep Questionnaire, which may assess a person’s level of daytime sleepiness or indicate if further evaluation is warranted.36 The use of a PSG test is often used to confirm a diagnosis of OSA. In addition to PSG, portable monitors can be used to diagnose OSA, although the measured AHI score can differ substantially from that measured with a PSG test, which takes place in a clinical setting.
In 2013, the American College of Physicians (ACP) issued new evidence-based guideline recommendations for diagnosing OSA in adults.37 These guidelines are designed to present clinical evidence and provide clinicians with recommendations on the diagnosis and management of OSA in adults. The ACP recommends a sleep study for patients with unexplained daytime sleepiness and also recommends polysomnography for diagnostic testing in patients suspected of OSA.37-39 In addition, the ACP recommends portable sleep monitors in patients without serious comorbidities as an alternative to PSG when it is not available for diagnostic testing.37-39
Health Implications Associated With Untreated OSA
Patients with untreated OSA are at a greater risk for developing several serious and clinically significant health issues from decreased daytime alertness, quality of life, and cognitive impairment to cardiovascular, neurologic, and metabolic morbidities, and eventually premature death.1,5,7,8
Neurologic Effects: Various clinical studies have reported the correlation between OSA and cognitive changes, such as periods of confusion, the inability to concentrate, or impairment of short-term memory.40 The cognitive impairments related to OSA are frequent occurrences and may negatively affect a patient’s ability to process information and impair attention span, executive functioning, learning and memory, alertness and sustained attention, visuospatial learning, motor performance, and constructional tasks. But fortunately, OSA normally does not appear to affect global cognitive functioning and language.40 Studies reveal that OSA patients appear to show signs of considerable brain damage, particularly in sites that control autonomic, cognitive, emotional, and breathing functions, which are deficient in the condition.41 Symptoms associated with injury to these areas of the brain are linked with higher rates of morbidity, mortality, and reduced quality of life as a result of untreated sleep apnea.41
Many patients with OSA complain of waking up with frontal headaches that typically resolve about 2 hours after awakening.40,42 These headache symptoms are believed to transpire due to the elevated levels of carbon dioxide retention after apnea and/or hypopnea episodes that result in cerebral vasodilatation.40 OSA patients may also experience mood or personality changes, including anxiety, panic attacks, depression, and irritability due to disrupted sleep patterns.40 In addition, patients may experience a decline in work and school performance; personal relationships often suffer because of the personality changes induced by sleep fragmentation and lack of REM sleep.40
Studies also reveal the extent to which untreated OSA impairs attention span in adults with the condition, which is similar to the effects of alcohol intoxication.43 Children with untreated OSA may present with symptoms comparable to those of attention-deficit/ hyperactivity disorder (ADHD) and experience inattention, impulsivity, hyperactivity, and aggression.41 Furthermore, researchers have concluded that since OSA and the effects of this condition appear to affect multiple levels of the central nervous system (CNS), OSA may indeed have a role in the development or exacerbation of many other neurologic diseases.44
A recent study suggests that OSA may have a role in contributing to dementia, including Alzheimer’s disease, and to its precursor, mild cognitive impairment.45 Research has revealed that untreated OSA may be a risk factor for progression of dementia, although a recent large community-based study suggested only a minor influence of moderate or severe OSA on cognitive function.45
Published studies have reported a connection between OSA and dementia in the elderly, with the severity of the dementia being related to the severity of the sleep-disordered breathing.45-48 In one study, Yaffe et al monitored 298 women without dementia (mean age 82 years) for approximately 5 years.49 Women with untreated OSA were more likely to develop mild cognitive impairment or dementia even after adjustment for other risk factors.49
In a recent study published in the Journal of Neuroimaging, Palomares et al reported the first evidence that OSA contributes to a breakdown of the blood-brain barrier, which plays an important role in protecting brain tissue.41 The findings are important for diseases such as multiple sclerosis, where compromised blood-brain barrier function is linked with subsequent brain damage caused by the disease. The study concluded that new developments may add to novel strategies for the treatment of OSA, as well as open up new therapeutic strategies for protecting against the breakdown of the blood-brain barrier.41
Cardiovascular Effects: Extensive research has shown that OSA has negative effects on cardiovascular physiology and causes increased platelet adhesiveness, vascular endothelial dysfunction, hypercoagulability, decreased cerebral blood flow, paradoxical embolization, and atherosclerosis.50 Research has also demonstrated that patients with OSA, particularly when it is moderate or severe and untreated, are at increased risk for an extensive range of cardiovascular morbidities, including systemic hypertension, pulmonary arterial hypertension, coronary artery disease, cardiac arrhythmias, heart failure, stroke, myocardial infarction, and ultimately, premature death.5,24,46,51-53
The relationship of OSA to cerebrovascular disease is still being investigated; however, there is growing evidence suggesting that the prevalence of OSA is augmented in patients who have had a stroke.51 Research is attempting to gain a deeper insight into understanding the correlation between sleep apnea and stroke, which in turn may encourage providers to screen patients more often to obtain an early diagnosis and initiate treatment of OSA to enhance the probability of recovery from stroke in the short term and to decrease the threat of recurrent stroke in the long term.53
In one study, Durgan and Bryan revealed that the frequency of OSA in patients who have had a stroke or transient ischemic attack (TIA) is greater than that of the general population.54 Patients presenting with stroke or TIA were 3 to 4 times more likely to have OSA than the control subjects.54 In another study, Palomaki concluded that snoring could be a risk factor for ischemic stroke, likely because of the higher incidence of OSA among snorers.55 Since OSA is very prevalent in individuals who have had a stroke, its emerging role as a possible modifiable risk factor for stroke has been documented in the most recent American Heart Association stroke guidelines, which recommend consideration of screening for and treatment of OSA.56
Metabolic Effects: The incidence of OSA is often associated with insulin resistance, glucose intolerance, and type 2 diabetes mellitus (T2DM), independent of obesity.57 Several large-scale, cross-sectional, and epidemiologic studies have suggested that OSA is an independent risk factor for the development of T2DM and that as many as 15% to 30% of patients with OSA also have T2DM.58 Moreover, as the severity of OSA increases, so does the likelihood of the incidence of T2DM and poor glycemic control in patients with T2DM.58 Results from a study conducted by Rattue et al reveal that OSA is also independently linked to diabetic peripheral neuropathy (DPN) in patients with T2DM.59 The researchers noted that the severity of the DPN is also associated with the degree of OSA as well as the severity of nocturnal hypoxemia.59
There is some clinical evidence to suggest that there may be strong correlations between the presence and severity of OSA and the metabolic disturbances associated with polycystic ovarian syndrome (PCOS), the most common endocrine condition occurring in premenopausal women that is associated with hyperandrogenism and insulin resistance.60 A study conducted by Vgontzas et al reported that women with PCOS were much more likely to have sleep-disordered breathing and daytime sleepiness, which suggests a pathogenetic role of insulin resistance in OSA.61 Clinicians who treat and manage patients with PCOS should be aware of the high incidence of OSA in this patient population and evaluate these patients for sleep disturbances and disorders such as OSA.60
Clearly, the results of various studies demonstrate the harmful effects associated with untreated OSA and the likelihood of various health complications. Therefore, it is imperative that healthcare professionals screen patients at risk for developing sleep apnea and encourage these patients to get tested and initiate treatment immediately, when warranted.
Treatment and Management
In the last two decades, advances in sleep medicine and the availability of improved diagnostic tools have led to increased awareness and treatment of OSA; however, the management of patients with OSA may require a multidisciplinary approach.62
CPAP Therapy: Findings from several studies have revealed the negative effects of sleep apnea on both the nervous and cardiovascular systems; however, these serious health risks can be decreased via treating sleep apnea with continuous positive airway pressure therapy, commonly known as CPAP.19,62,63 CPAP, which is the most consistently successful and extensively studied treatment of OSA, is considered to be the gold standard treatment of choice for OSA.5,24 A new study in the Journal of Neurophysiology supports the continual use of CPAP as a sleep apnea treatment, and results revealed that CPAP therapy may reverse some of the health complications such as cardiovascular disease.64 CPAP improves breathing during sleep, resulting in better blood oxygen saturation and less sleep fragmentation.64-66 In addition, studies reveal that routine CPAP treatment will improve daytime functioning.67
Although CPAP is established as a highly efficacious treatment for OSA, patient compliance to this standard therapy is often poor and a major issue for OSA patients. Many patients often experience nasal discomfort, congestion, mask leakage, and claustrophobia, which lead to erratic levels of long-term compliance ranging from 46% to 85%, depending on how compliance is defined.66 Despite the effectiveness of CPAP therapy, many patients will not remain compliant, and some surveys report noncompliance rates as high as 50%.66-68 Common complications that contribute to patient noncompliance include difficulty falling asleep with the mask, improper fit of mask, nasal dryness and congestion, facial skin abrasions, air leaks, and conjunctivitis.66-68
A number of earlier studies have investigated the effects of CPAP treatment and low compliance.67 Although adherence is sometimes defined as usage for >4 hours per night for more than 70% of nights for the purposes of insurance reimbursement in the U.S., there does not appear to be a clear threshold above which adverse effects of OSA reverse.66
While CPAP therapy is not curative, studies have revealed that continual use lessens apneic episodes, hypersomnolence, mood changes, anxiety, and cognitive impairments. CPAP therapy also decreases blood pressure, improves insulin sensitivity in patients with T2DM, and reduces the risk of stroke, congestive heart failure, coronary artery disease, and irregular heart rates.66
Patient compliance is essential to effective treatment, and immediate improvement in symptoms is often observed following CPAP therapy. The optimal pressure for CPAP therapy is individualized and determined during the sleep study and can range from 3 to 20 cm H2O.5,66 Bilevel positive airway pressure (BiPAP) therapy, which uses two different airway pressures, is often employed in patients who cannot tolerate high CPAP pressures.5 Since patient compliance is often low with regard to CPAP therapy, healthcare professionals should try to implement strategies to increase patient compliance, such as allowing the patient to try various types of masks and less invasive nasal pillows, adding humidification to treat nasal dryness, conducting routine follow-up, providing patient education and support programs, and encouraging patients to use the CPAP machine every time they sleep, including naps to prevent recurrence of symptoms and to decrease incidence of health complications.
Adjunctive Therapies: To date, there are no FDA-approved pharmacologic agents available for treating OSA; however, adjunctive therapies are often utilized for treatment of nasal allergies and residual sleepiness, if warranted.5,24,69 Adjunctive treatments are commonly used, but have no proven role as first-line treatment.5 Modafinil can be used for residual sleepiness in OSA in patients who are effectively using CPAP.5 This agent is FDA approved to improve wakefulness in adult patients with excessive sleepiness associated with OSA.70 Modafinil is classified as a 1:1 racemic compound whose enantiomers have different pharmacokinetics. While modafinil’s exact mechanism of action is unknown, it is thought to increase dopamine levels in the brain via binding to the dopamine transporter and inhibiting dopamine reuptake. This agent is readily absorbed after oral administration and is hepatically metabolized. The recommended dosage of modafinil is 200 mg taken daily in the morning. The most common adverse effects include headache, nausea, nervousness, rhinitis, diarrhea, back pain, anxiety, insomnia, dizziness, and dyspepsia.70
Armodafinil, which is the R-enantiomer of modafinil, is also FDA approved to improve wakefulness in adult patients with excessive sleepiness associated with OSA.71 The recommended dose of armodafinil is 150 to 250 mg once daily in the morning. The most common adverse effects reported included headache, nausea, dizziness, and insomnia.71 Pharmacists should advise patients to avoid alcohol and to not operate a motor vehicle or engage in other dangerous activities until they become familiar with their reaction to these two drugs.70,71
The use of oral appliance therapy (e.g., a mouth guard) has emerged as an important alternative to CPAP in treating patients with OSA. In a study conducted by Doff et al, the researchers concluded that oral appliance therapy should be considered as a viable treatment alternative to CPAP in patients with mild-to-moderate OSA, and these devices are intended to increase the volume of the airways through a mechanical maneuver.72,73 In patients with severe OSA, CPAP remains the initial treatment of choice and every measure should be employed to increase a patient’s compliance to therapy.73 Several studies report that oral appliances are a good alternative for the treatment of snoring and OSA due to their low cost, relative comfort, and ease of use, which may increase patient compliance.73
Other OSA treatment options include establishing a sleep hygiene routine, which involves withdrawal from alcohol and other sedatives, weight loss if warranted, and proper body position by avoiding sleeping in the supine position (which is associated with more frequent and severe episodes of apnea). Surgical procedures include glossectomy, uvulopalatopharyngoplasty, and maxillomandibular advancement.5,73,74 Please refer to TABLE 3 for a summary of OSA therapies.5,73-76
On May 1, 2014, the FDA approved the first implanted medical device for OSA.69 The Inspire Upper Airway System is indicated for patients with moderate-to-severe OSA who have specific characteristics such as BMI <32 and the absence of complete collapse in the back of the throat who have not been helped by a CPAP device, or could not tolerate the CPAP treatment. The Inspire device is surgically implanted below the collarbone and works with electrical impulses to stimulate the patient’s tongue muscles and keep airways open.69
Role of the Pharmacist
Many individuals may perceive snoring as a simple nuisance, but in some cases it may be a sign of OSA. Pharmacists are in a pivotal position to identify those pharmacologic agents that may exacerbate the symptoms of OSA, including CNS depressants such as alcohol, benzodiazepine receptor agonists, barbiturates, antiepileptic drugs, sedating antidepressants, antihistamines, and opiates that may also have an impact on sleep quality and architecture.5,75,77
As one of the most trusted and easily accessible healthcare professionals, pharmacists can help increase awareness about OSA and recommend measures that may increase patient compliance to CPAP and other therapies. One of the first steps in identifying OSA is to recognize its signs and symptoms by having a thorough clinical knowledge of the condition, including its warning signs, and assist healthcare professionals in making referrals, a diagnosis, and suggesting initiation of treatment.40
Pharmacists are likely to encounter patients exhibiting signs of OSA or those at risk for OSA, and they should encourage those patients to seek further evaluation from their primary healthcare provider. It is imperative for all healthcare professionals to seriously seize every opportunity to increase awareness about OSA, help patients at risk to understand the grave health consequences associated with untreated OSA, and provide patients with the essential information needed to manage this life-threatening disorder. Treating OSA and remaining compliant to therapy will not only enable patients to finally get a good night’s sleep every night, but more importantly, compliance to therapy may actually prevent critical health issues and even premature death.
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- Huang Q, Qin Z, Zang S, Chow CM. Clinical patterns of obstructive sleep apnea and its comorbid conditions: a data mining approach. J Clin Sleep Med. 2008;4(6):543-550.
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- Obstructive sleep apnea. Neurology Now. 2007;3(3):46-47. http://journals.lww.com/neurologynow/Fulltext/2007/03030/Obstructive_Sleep_Apnea.32.aspx. Accessed September 3, 2015.
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- Louis E. Diagnosing and treating comorbid sleep apnea in neurological disorders, part I. Pract Neurol. 2010;9(4):26-30.
- Silverberg D, Iaina A, Oksenberg A. Treating obstructive sleep apnea improves essential hypertension and quality of life. Am Fam Physician. 2002;65(2):229-237.
- Louis E. Diagnosing and treating co-morbid sleep apnea in neurological disorders, part II. Pract Neurol. 2010;9(5):26-31.
- Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemio logical aspects of obstructive sleep apnea. J Thorac Dis. 2015;7(5): 920-929.
- May TS. Treatment of comorbid sleep disorders improve seizure control. Psychiatric Times. June 1, 2007. www.psychiatric-times.com/articles/treatment-comorbid-sleep-disorders-improves-seizure-control. Accessed September 10, 2015.
- Gharibeh T, Mehra R. Obstructive sleep apnea syndrome: natural history, diagnosis, and emerging treatment options. Nat Sci Sleep. 2010;2:233-255.
- Vijayan V. Morbidities associated with obstructive sleep apnea. Medscape. www.medscape.com/viewarticle/775550. Accessed September 8, 2015.
- Sleep apnea more than doubles risk for car accidents; the dangers of driving drowsy. Medical Daily. May 11, 2015. www. medicaldaily.com/sleep-apnea-more-doubles-risk-car-accidents-dangers-drowsy-driving-325210. Accessed September 1, 2015.
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