0

Unpeaceful Sleep
Snoring could be sign of undiagnosed sleep apnea

WASHINGTON - Loud snoring doesn't just annoy your spouse. It could signal dangerous sleep apnea, yet millions go undiagnosed.

A government move may help change that: Medicare is poised to allow at-home testing for sleep apnea - letting people snooze in their own beds instead of spending the night in a sleep laboratory.

It's a controversial proposal, but a potentially far-reaching one. Some 18 million Americans are estimated to suffer from sleep apnea, yet specialists think fewer than half know it.

'It's been awkward and inconvenient and expensive to get a sleep test, and now that should be improved,' says Dr. Terence Davidson of the University of California, San Diego, a longtime proponent of home-testing.

Today, Medicare pays for sleep apnea treatment - called CPAP, a mask that blows air through the nose while sleeping - only for seniors diagnosed in a sleep lab. Last month, Medicare proposed covering those diagnosed with cheaper home tests, too. The public may comment on the proposal until next week; final approval is expected in March.

While sleep apnea is a problem for seniors, it is most common in middle-aged men. But private insurers now reluctant to cover home apnea testing are expected to follow the government's lead, thus easing access for all ages.

Sleep apnea doesn't just deprive family members of their own zzzz's. Sufferers actually quit breathing for 30 seconds or so at a time, as their throat muscles temporarily collapse. They jerk awake to gasp in air, sometimes more than 15 times an hour. They're fatigued the next day because their brains never get enough deep sleep.

Severe apnea increases the chance of a car crash sevenfold. Research from UCSD suggests 1,400 deaths each year are caused by drivers with sleep apnea.

Worse, sleep apnea stresses the body in ways that also increase risk of high blood pressure, heart attack, stroke and diabetes.

Not every apnea patient is a bad snorer, and a low rumble may not be cause for concern. But sleep apnea's trademark is bad snoring - the snorting, choking kind. Other risk factors: Being overweight, having small airways or having apnea in the family.

Yet patients don't remember the nightly breathing struggle, and often don't see a doctor unless a family member complains about snoring - or until daytime sleepiness gets so bad they can't function.

Only then comes the test debate.

There are dozens of sleep disorders. A night slumbering in a sleep lab, hooked to monitors that measure both breathing and brain waves while health workers watch, has long been the standard for telling who has sleep apnea or another disorder.

But this lab-based polysomnography, or PSG, can cost $1,500. And while access has improved, there are swaths of the country where reaching a sleep lab can mean a few hundred miles' drive.

For about $500, home tests use primarily breathing monitors to detect only sleep apnea, not other disorders. Hook it up at bedtime, and a doctor checks the recordings later.

A home test can miss apnea, because it won't signal if someone never fell into that deep REM sleep where breathing is most likely to falter, says Dr. Thomas Gravelyn of the Saint Joseph Mercy Hospital sleep center in Ann Arbor, Mich., who opposes the Medicare change.

'You have this good feeling that everything was taken care of, when in fact it wasn't,' he says.

'It certainly is possible to diagnose severe apnea at home,' adds Dr. Joyce Walsleben, chief of New York University's sleep center. 'What if it isn't severe? Are you willing to say it doesn't exist at all if you get a negative study?'

Still, a Canadian study published last year randomly assigned suspected apnea sufferers to either a sleep lab or home testing, and found they worked equally well.

Last month, the American Academy of Sleep Medicine, which represents sleep centers, changed its position to say home tests can help certain high-risk patients - but should be administered by sleep specialists.

Medicare's proposal wouldn't limit which doctors offer home tests. The American Academy of Otolaryngology, head-and-neck surgeons, requested the change.

In fact, Medicare concluded a sleep-lab test isn't perfect, either - and thus proposed that all patients get a 12-week trial of CPAP treatment. Only if their doctors certify they're being helped would treatment continue.

That's important, because about half of apnea patients prescribed CPAP struggle to use it, says Dr. Charles Atwood of the University of Pittsburgh Medical Center, a home-test proponent. What he calls tricks of the trade - trying differently shaped masks, adjusting the air pressure, adding a humidifier to moisten nostrils - early could keep more of them in care.

Consider Raymond Miles, 57, diagnosed with a sleep-lab study a few years ago. While he felt better with CPAP treatment, Miles quit it in frustration when he couldn't get help maintaining it.

Two weeks ago, nudged by his wife, Miles underwent a home test with a different doctor to see if it's time to try care again.

'There's a different level of comfort being at home,' Miles says of the testing.