Advancing Care - September 2022

When being sleepy is a problem

You’re exhausted, even though you turned in early. Your partner complains about your disruptive snoring. Should you call your doctor? If the problem interferes with a good night’s sleep more often than not,  you should talk to your doctor, said Amit Khanna, MD, medical director at Lawrence + Memorial Sleep Center, and a sleep medicine specialist with Northeast Medical Group. You may have a sleep-related disorder.

What is sleep apnea?

Obstructive sleep apnea (OSA) is the most common sleep-related disorder. While you sleep, your throat muscles relax and narrow, blocking your airways so you aren’t taking in enough oxygen. This causes short periods where you are not breathing followed by gasps for air. A classic symptom is snoring. These repeated interruptions prevent the brain from entering the deepest, most restful sleep. People often wake up feeling very tired, even though the clock says they had a full night’s rest.

“Untreated sleep apnea can increase your risk of serious complications, including hypertension, coronary artery disease, cardiac arrhythmias, type 2 diabetes, heart failure and stroke,” Dr. Khanna said.

Obstructive sleep apnea can contribute to memory and cognitive deficits, factors that may lead to errors in judgment. Motor vehicle accidents due to drowsy driving, for example, are two to three times more common among people with OSA.

What are the symptoms of sleep apnea?

“The most common symptom is excessive daytime sleepiness where patients have difficulty maintaining wakefulness or alertness at appropriate times during the day," Dr. Khanna said.

He notes that it is important to distinguish fatigue (a lack of physical or mental energy) from sleepiness (an inability to stay awake). People with sleep apnea may also snore or make wheezing, choking, snorting or gasping sounds during sleep, which can be frightening for parents, caregivers or bed partners. In some cases, people with sleep apnea may wake up with headaches or a dry mouth or throat.

What are the risk factors?

Sleep apnea is seen in all age groups, from infants to the elderly, yet the causes may differ. While men are at a much higher risk than women, the risk for women increases after menopause.

Other risk factors include being overweight, smoking, age, use of narcotics, heart disease or a history of stroke.

Treatments for sleep apnea

If you have been diagnosed with sleep apnea, your doctor may recommend that you lose weight, quit smoking, and avoid alcohol and heavy meals in the hours before bedtime. Sleeping on your side instead of your back allows the airway to remain open. Elevating the head of your bed may also provide relief.

Your doctor may also recommend bilevel positive airway pressure (BPAP) therapy or CPAP (continuous positive airway pressure) appliance, the “gold standard” for treating sleep apnea. This device consists of a blower that delivers a small amount of air pressure through a mask that fits over your nose to keep your airway open while you sleep.

Despite its effectiveness, patients may struggle with wearing the mask and stop using a CPAP. “It takes time and effort to get used to using a CPAP,” said sleep medicine specialist Vivian Asare, MD, associate medical director, Yale Centers for Sleep Medicine. She facilitates a virtual CPAP support group via Zoom on the first Friday of every month at 3 pm. To attend the virtual group, call 203-432-9666 at the scheduled time and enter the meeting ID number (921 4861 3236) and passcode (463881) when prompted, or log into Zoom.

“Our support group meetings offer participants the opportunity to ask questions, trade helpful tips and share experiences that help people better understand and manage their sleep-related concerns,” she said.

Other nonsurgical treatment options include custom-fit dental appliances that move the lower jaw forward so that the tissues of the back of the throat relax and prevent the tongue from collapsing and blocking the airway.

For patients who cannot tolerate a CPAP or who have trouble with other treatments like oral appliances or weight loss, surgical treatment options include the Inspire upper airway stimulation device. Inspire is a small, electrical device implanted in the patient’s chest, like a pacemaker. Connected wirelessly to a remote, the activated device stimulates the airway muscles, so they remain open during sleep.

“Inspire is different from CPAP because it keeps airways open from inside the body,” Dr. Asare said. “It’s not appropriate for all sleep apnea sufferers, so you should talk to your doctor about whether it is right for you.”

If you notice any of the signs of sleep apnea, it’s important to mention it to your doctor. “So many people don’t know what normal, refreshing sleep feels like,” she said. “Treating your sleep apnea truly can change your life for the better.”

5 signs you may have osteoarthritis

As you get older, you may find yourself coping with aches and pains on occasion, especially if you participate in physical activities. However, if you start experiencing aching, pain and stiffness regularly — particularly if the pain is at the joint — you may be developing osteoarthritis.

Arthritis describes more than 100 different conditions that affect joints and the surrounding tissue. Osteoarthritis, sometimes referred to as degenerative arthritis or degenerative joint disease, is the most common. It can develop after trauma or from age-related wear and tear on your joints, according to Cristina M. Brunet, MD, a Yale Medicine rheumatologist with practices in Old Saybrook and North Haven.

Wear and tear on the joint leads to the breakdown of cartilage, the rubber-like padding that covers and cushions the ends of the bones, allowing them to easily move against each other. As the cartilage breaks down, bone becomes more exposed. Eventually one bone starts to rub against another, causing pain, damage, swelling and problems with motion.

“Anyone may develop osteoarthritis and the risk gets higher as we age,” Dr. Brunet said. “It develops in some people when they reach their 60s, although certain individuals may be at risk for osteoarthritis at younger ages due to prior injury or a familial tendency. At times, it develops after a sports injury, with repeated stress, or after surgery.”

Excess weight may also contribute to developing osteoarthritis in weight-bearing joints, such as the hips or knees. The disease may also be associated with certain metabolic diseases such as iron overload or diabetes.

What are the early signs of arthritis?

• Pain in a joint. Pain or aching in a joint that gradually becomes worse over time is a classic symptom of arthritis. The pain may be triggered by activity, or it may arise after activity or at the end of the day. Osteoarthritis is most likely to affect weight-bearing joints such as the knees, hip, lower spine or big toe, but it can also cause pain and stiffness in your thumb or finger joints.
• Joint swelling and tenderness. As arthritis gets worse, it can cause joints to be swollen and tender, making it difficult to move the joint, or to bear weight on the joint. 
• Pain in a joint that was previously injured. Many cases of osteoarthritis occur in a part of the body that suffered a prior injury or trauma. “It’s worth seeking evaluation for persistent joint symptoms,” Dr Brunet said. 
• Grating sound or sensation. Grinding or grating as a joint moves is a sign the cartilage in your joint has worn down and can indicate arthritis. It’s most common in the knee and hip but can affect other joints too.
• Groin pain. Many people don’t realize pain from hip arthritis radiates to the groin, not the outside of the hip. Hip arthritis can also cause pain in your thigh or buttocks.

What can I do to help ease my pain?

There is no cure for osteoarthritis – but if diagnosed early, you may be able to slow its progression. Exercise can be one of the best treatments. “Osteoarthritis pain is best managed by staying active through exercise,” said Sung Park, PT, manager of L+ M Outpatient Rehabilitation Services in East Lyme and Waterford.

Walking – as long as it does not cause pain – is a good exercise; however, it is best to avoid running. Consider a low-impact exercise, such as bicycling or swimming, to reduce wear and tear on your weight-bearing joints, Park said.

“The type of exercise is dictated by a patient’s response to it. If it causes pain, find an alternative activity,” he said. “Swimming is very good for patients who have trouble with weight-bearing activities like walking, because the buoyancy of the water prevents pressure on the joints while also providing resistance that is beneficial.”

Studies have shown that regular yoga practice can decrease pain and improve joint flexibility for people with osteoarthritis. Park suggests trying yoga while sitting in a chair or lying on the floor if standing is uncomfortable.

Other treatments may include:

• Topical pain relievers such as lidocaine creams and over-the-counter non-steroidal anti-inflammatory drugs (NSAIDS)or injectable steroids for more severe persistent pain.
• Ice packs and/or heating pads.
• Physical therapy to improve flexibility, strength and range of motion.

Your doctor may also suggest that you lose weight. Being overweight increases risk of developing osteoarthritis because carrying too much weight over time puts unhealthy pressure on the joints, causing the cartilage that supports that weight to break down faster.

If your pain is getting worse, it’s best to talk to a doctor. “Consultation with a physiatrist, a specialist in physical medicine and rehabilitation, may be helpful in non-surgical management of mechanical causes of arthritis,” Dr. Brunet said. “Any symptoms that are progressive may need to be evaluated by orthopedics for consideration of surgical intervention.”

Preventing falls: Make your home a safer place

As you get older, physical changes and health conditions – and sometimes the medications used to treat those conditions – make falls more likely. Falls, in fact, are a leading cause of injury among older adults.

Fractures of the wrist, shoulder and/or pelvis can have a devastating effect on independence. Falls are the cause of most broken hips, and only half of those who break their hip say that they get around as well as they did before their injury.

Take a few proactive, easy steps to prevent falls at home. You can:

• Begin an exercise program. Even something simple like walking improves your balance, coordination and muscle strength. Ask your doctor about the best exercises for you.
• Have your healthcare provider or pharmacist review your medications. Some medications may interact with others to make you dizzy or sleepy. Even over-the-counter medications can increase your risk of falling.
• Have your vision checked at least once a year. Glaucoma or cataracts can increase your risk of falling.

Here are a few steps to make your home safer:

• Create a clear walking path through rooms. Ask someone to move the furniture so don’t have to walk around it.
• Remove throw rugs or use double-sided tape to keep them in place.
• Reduce clutter. Don’t leave things on the floor or stairs because they become trip hazards.
• Secure power cords for appliances, lighting and electronic devices next to the wall to prevent tripping over them. If needed, have an electrician put in another outlet.
• Avoid using step stools. Keep frequently used items in a low cabinet for easy access. If you must use a step stool, get one with a hand grip. Never use a chair as a step stool.
• In the bathroom, install grab bars near your toilet and in your tub or shower. Use nonslip mats in bathtubs and showers.
• Improve the lighting in your home:
  • Put in brighter light bulbs.
  • Install an overhead light at the top and bottom of the stairs, along with light switches in both locations.
  • Use a nightlight so you can see the path from your bed to the bathroom.
• Install handrails and lights on all staircases. Fix any loose or uneven steps.
• Paint a contrasting color on the top edge of each step so you can see the stairs better. For example, use a light-color paint on dark wood.
• Keep your home at a comfortable temperature. Extreme heat or cold can make you dizzy and unsteady on your feet.
• Get up slowly after you sit or lie down.
• Wear supportive shoes when you are inside as well as outside. Choose shoes that fit snugly with no-slip soles and a flat or low, wide heel. Avoid going barefoot. Don’t wear slippers, flip-flops, backless shoes, high heels or shoes with smooth leather soles.
• Keep emergency numbers in large print near each phone.
• Put a phone near the floor in case you fall and can’t get up.
• Wear a personal safety alarm.

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