In another study, obstructive sleep apnoea has also been found to slow down processing powers in the elderly; in particular, those aged 74 years or more and men showed a steeper decline in certain cognitive tests.

A third study found that patients with more severe obstructive sleep apnoea were at greater risk of developing blood clots in their veins — a potentially life-threatening condition.

OSA and cancer

Dr Andreas Palm, a researcher and senior consultant at Uppsala University, Sweden, who presented the first study, said: “It is known already that patients with obstructive sleep apnoea have an increased risk of cancer but it has not been clear whether or not this is due to the OSA itself or to related risk factors for cancer, such as obesity, cardiometabolic disease and lifestyle factors. Our findings show that oxygen deprivation due to OSA is independently associated with cancer.”

Dr Palm and colleagues looked at data from 62,811 patients five years prior to the start of treatment for OSA in Sweden. Between July 2010 and March 2018, patients were treated with continuous positive airway pressure (CPAP), which provides a positive pressure of air through a mask to keep the airways open during sleep. The researchers linked these data with data from the Swedish National Cancer Registry and socio-economic data from Statistics Sweden.

The researchers took account of factors that could affect the results such as body size, other health problems and socio-economic status. They matched 2,093 patients with OSA and a diagnosis of cancer up to five years before OSA diagnosis with a control group of 2,093 patients with OSA but no cancer. They measured the severity of OSA with the apnoea hypopnea index (AHI), which measures the number of breathing disturbances during sleep, or the oxygen desaturation index (ODI), which measures how many times an hour levels of oxygen in the blood fall by at least 3% for ten seconds or longer.

“We found that patients with cancer had slightly more severe OSA, as measured by an apnoea hypopnea index average of 32 versus 30, and an oxygen desaturation index of 28 versus 26,” he said. “In further analysis of subgroups, ODI was higher in patients with lung cancer (38 versus 27) prostate cancer (28 versus 24) and malignant melanoma (32 versus 25).

“The findings in this study highlight the need to consider untreated sleep apnoea as a risk factor for cancer and for doctors to be aware of the possibility of cancer when treating patients with OSA. However, extending screening for cancer to all OSA patients is not justified or recommended by our study results.”

So far only correlation, not causation established

The study only looked at data from one point in time and it cannot show that OSA causes cancer, only that it is associated with it. Some important lifestyle factors such as physical activity and food preferences were not captured on an individual basis in the study. The main strength of the study is its large size and the high quality of data on cancer diagnosis and OSA.

In the future, Dr Palm and his colleagues plan to increase the number of patients and to follow the patients over time to study the potential influences of CPAP treatment on cancer incidence and survival. “The association between OSA and cancer is less well established than the link with diseases of the heart and blood vessels, insulin resistance, diabetes and fatty liver disease,” he said. “Therefore, more research is needed, and we hope our study will encourage other researchers to research this important topic.”

OSA and decline in mental processing powers

In a second presentation ^[2], Professor Raphaël Heinzer, director of the Centre for Investigation and Research on Sleep (CIRS) at Lausanne University, Switzerland, told the congress that the study conducted by his colleague Dr Nicola Marchi showed that OSA was linked to a greater decline in mental processing powers over a period of five years.

Professor Heinzer, Dr Nicola Marchi, of Lausanne University Hospital, and colleagues studied people aged 65 years and over from the general population of Lausanne who were recruited to the CoLaus/PsyCoLaus and HypnoLaus studies between 2003 and 2008, and who were followed up every five years. A total of 358 participants took a sleep test to examine the presence and severity of OSA when they joined the studies. During the first follow-up between 2009 and 2013, their mental processing abilities were also tested and another cognitive assessment took place during the second follow-up five years later.

The cognitive tests assessed global cognitive function (knowledge and reasoning skills), processing speed (time taken to understand and react to information), executive function (ability to organise thoughts and activities, prioritise tasks and make decisions), verbal memory, language and visual perception of spatial relationships between objects (visuospatial function).

Speaking before the congress, Dr Marchi said: “We found that OSA and, in particular, low oxygen levels during sleep due to OSA, was associated with a greater decline in global cognitive function, processing speed, executive function and verbal memory. We also found that people aged 74 and older and men were at higher risk of cognitive decline related to sleep apnoea in some specific cognitive tests.”

For example, the Stroop test, which measures processing speed and executive function, showed a steeper decline in people aged 74 and older compared to younger participants, and the verbal fluency test showed a steeper decline in men only but not in women.

“This study demonstrates that the severity of sleep apnoea and night-time oxygen deprivation contribute to cognitive decline in old age. It also shows that sleep apnoea is related to a decline in specific cognitive functions, such as processing speed, executive function and verbal memory, but not to a decline in all cognitive functions; for instance, language and visuospatial function were not affected,” said Dr Marchi.

The risk of cognitive decline is not the same in all OSA patients

“People with OSA and doctors should be aware that OSA may play a role in cognitive decline. However, to date, OSA treatment with continuous positive airway pressure (CPAP) has not been clearly demonstrated to prevent cognitive decline. Our study suggests that probably not all OSA patients have the same risk of cognitive decline; there is probably a subgroup of patients, particularly those with greater nocturnal oxygen deprivation but also older patients and men, who could be at greater risk of OSA-related cognitive decline,” he said.

The researchers plan to analyse data on the impact of OSA after ten years to find out more about who is at most risk of cognitive decline related to OSA. Dr Marchi suggests that performing a randomised controlled trial with these patients in order to investigate the effect of CPAP on cognition should be the next step after that.

Strengths of the study include that it followed people over a five-year period, assessment of OSA was performed with the “gold standard” polysomnography test, and that several tests were used to evaluate a range of cognitive processes. Limitations include that the participants were relatively healthy, without severe cognitive impairment or dementia and that OSA was assessed only at the beginning of the study.

Obstructive Sleep Apnoea and blood clots

A third study ^[3], presented by Professor Wojciech Trzepizur, from Angers University Hospital, France, showed that patients with more severe OSA, as measured by AHI and markers of nocturnal oxygen deprivation, were more likely to develop venous thromboembolism (VTE). Out of 7,355 patients followed over more than six years, 104 developed VTEs.

“This is the first study to investigate the association between obstructive sleep apnoea and the incidence of unprovoked venous thromboembolisms. We found that those who spent more than 6% of their night-time with levels of oxygen in their blood below 90% of normal had an almost two-fold risk of developing VTEs as compared to patients without oxygen deprivation,” said Professor Trzepizur. “Further studies are required to see whether adequate treatment for OSA, for instance with CPAP treatment, might reduce the risk of VTEs in patients with marked nocturnal oxygen deprivation.” ^[4]

The correlations are worrying

Professor Winfried Randerath, of the Bethanien Hospital at the University of Cologne, Germany, is head of the ERS specialist group on sleep disordered breathing and was not involved in the three studies. He commented: “These three studies show worrying associations between obstructive sleep apnoea and important diseases that affect survival and quality of life. The data support the relevance of sleep apnoea on cancer, venous thromboembolisms and mental health. While they cannot prove that OSA causes any of these health problems, people should be made aware of these links and should try to make lifestyle changes in order to reduce their risk of OSA, for instance, by maintaining a healthy weight. However, if OSA is suspected, definite diagnosis and treatment should be initiated. We look forward to further research that may help to clarify whether OSA may be causing some of the health problems seen in these studies.”

References

[1] Abstract no: OA2290, “Cancer prevalence is increased in obstructive sleep apnea – the population-based DISCOVERY study”, presented by Andreas Palm.
[2] Abstract no: OA2287, “Obstructive sleep apnea and cognitive decline in the elderly population: the HypnoLaus study”, presented by Nicola Andrea Marchi.
[3] Abstract no: OA2288, “Sleep apnea and incident unprovoked venous thromboembolism: Data from the French Pays de la Loire Sleep Cohort”, presented by Wojciech Trzepizur.
All three abstracts are presented in the “Obstructive sleep apnea consequences and management” session, 11.15-12.30 hrs CEST on Monday 5 September 2022: https://k4.ersnet.org/prod/v2/Front/Program/Session?e=377&session=14833
[4] A “provoked VTE is one that happens following a major VTE risk factor, such as ongoing cancer and recent hospitalisation for surgery. A VTE is considered “unprovoked” when no major risk factor is identified.

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Though most adults need 7 – 8 hours of sleep to feel alert and energetic through the day, the need for sleep is as unique as our fingerprints. For you, it can be eight hours, for your spouse, seven hours, while your best friend could do with just six-and-a-half hours. If you’re looking for a magic number then there isn’t one, but there is some recent evidence that sleeping less than seven hours per night can be harmful in the long run.

Why should you aim for at least seven hours

Until recently we did not have a clear-cut, evidence-based recommendation regarding the duration of sleep needed for a healthy life. But, in June 2015, after reviewing 5314 scientific articles, a panel of 15 experts from the American Academy of Sleep Medicine and the Sleep Research Society concluded that adults need seven or more hours of sleep every night.

Here are their specific recommendations:

1. Sleeping less than seven hours each night is linked to adverse health conditions such as weight gain, diabetes, high blood pressure, heart disease, stroke and depression. It is also associated with lowered immunity, increased sensitivity to pain, impaired performance, increased chances of errors, and greater risk of accidents.
2. Sleeping more than nine hours per night on a regular basis may be appropriate for young adults, individuals recovering from sleep debt, and those with illnesses. For others, it is uncertain whether sleeping more than nine hours per night is associated with any health risk.
3. People who are concerned that they are sleeping too little or too much should consult their healthcare provider.

Life is so precious. Why waste one third of it sleeping?

One question that many people often ask is, “I’ve achieved so much in my life by sleeping less, can I not just continue that way?” The answer is: “No, you cannot. Not for long.”

Dr Van Dongen and colleagues at the University of Pennsylvania studied participants after four, six, and eight hours of sleep for 14 days and found a significant dose-dependent decline in their neurological and cognitive performance. Thus, by sleeping less, you may read more, but you will remember less. You may check more e-mails, but your responses will not reflect your true leadership skills. You may interact with more people, but you will be less perceptive. You may work on more problems, but your solutions will be less creative. In short, if you are sleeping less, you might be a liability, as opposed to an asset.

So, by compromising on your sleep you not only increase your risk of diseases mentioned above, but also impair your executive function—creativity, problem-solving, communication, and goal-directed behaviour. These are the reasons why business giants like Warren Buffet, Bill Gates and Satya Nadela try to get 7 – 8 hours sleep despite their busy schedules.

Bill Gates says he gets at least seven hours of sleep a night because “that’s what I need to stay sharp and creative and upbeat.” Jeff Bezos, CEO of Amazon, says, “I’m more alert, and I think more clearly if I’ve had eight hours’ sleep. I just feel so much better all day long if I’ve slept that much.” Marc Anderson, co-founder of Netscape, admits to needing eight hours. He says, “I can get by on seven-and-a-half hours without much trouble. Seven, and I start to degrade. Six is suboptimal. Five is a big problem. Four means I am a zombie.”

What about people who claim to do well with little sleep

What about Indira Gandhi, Margaret Thatcher, Indra Nooyi and the likes, who claimed to sleep only 4 – 5 hours a night? Do they carry a short-sleeper gene? Well, Dr Ying-Hui Fu and her  team at the University of California, San Francisco, did find that short-sleeper gene, a rare mutation, is present in three per cent of the population. But it has not been confirmed if there are other health risks of carrying this short-sleeper gene and sleeping so little.

Motivation cannot happen in the absence of creativity, flexibility and the right mood. All of which get hampered due to lack of sleep

My overworked colleagues continue to argue against sufficient sleep. Here is a list of arguments made by these sceptics and my responses:

1 “I don’t need eight hours of sleep.”

Studies have shown that restricting sleep to four or six hours [compared to eight hours] for 14 days causes a decline in your executive function.

2 “I can fight sleep deprivation with strong motivation.”

Motivation cannot happen in the absence of creativity, flexibility and the right mood. All of which get hampered due to lack of sleep.

3 “I have achieved a lot by sleeping less.”

You could achieve even more by sleeping more.

4 “I don’t perceive the deficit in my performance.”

Sleep deprivation adversely affects the prefrontal cortex [area of the brain called “the executive centre”], which is essential for successful self-evaluation. This makes us unaware of our deficit.

5 “I am highly productive even with less sleep.”

You have increased your output as a worker at the expense of leadership output. You are compromising the quality at the expense of quantity.

Sleeping eight hours but it still seems less

I have made my case for 7 – 8 hours of rest every night, but what if you are feeling sleepy and tired despite sleeping eight hours every night?

First, make sure you are getting quality sleep by following good sleep habits—keeping a regular sleep schedule even on weekends, exercising 30 minutes a day, not working in the bed, avoiding caffeine after 1pm, not eating a large meal before bedtime, not consuming alcohol within three hours of bedtime and most importantly, praying or meditating for a few minutes before retiring to bed. Then, make sure you do not suffer from depression or Obstructive Sleep Apnoea, a disease characterised by loud snoring and cessation of breathing for 10 or more seconds all night long.

In conclusion, invest richly in sleep and get the most out of your limited stay on this beautiful earth. Make a commitment, as a family, to get 7 – 8 hours of rest every night. Enjoy lasting alertness, energy, vigour, and vitality; and live a healthy, happy, and a long life.

I leave you with a favourite shloka of mine from the Bhagvad Gita [Chapter 6, Verse 17]

yuktahara-viharasya yukta-cestasya karmasu,
yukta-svapnavabodhasya, yogo bhavati duhkha-ha
(Translation: A person who is temperate in eating, resting, working and recreation can mitigate all material pains by practising yoga.)

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Easy does it

• Develop a regular sleep-wake schedule. Whether or not you’ve had a good nights rest, if you’re trying to establish a good sleep schedule you will have to get out of bed on time.
• Conserve your bed as a sanctuary meant only for sleep and sex. Don’t read or watch TV while relaxing on the bed
• Try to make your bedroom as comfortable as possible. It should be airy, quiet and dark.
• If your mind is lost in thought about something that disturbs your sleep, write it down on a notepad. Put it off till the morning
• Don’t try too hard to go to sleep. Wait for about half-an-hour, and if you don’t feel sleepy, do something else instead. Go back to sleep only when you feel sleepy.
• Avoid bright lights. They only tell your body one thing – that it is time to get up!
•  If you cannot resist the bait of a “well-earned” nap, it should always be before 4.00 PM and not for more than 20 minutes.
• Exercise is good for you but not when done too close to bed time. Avoid exercise two-three hours before your sleep time. Exercise increases the level of endorphins in your body which makes it difficult to calm down and go to bed.
• If you suffer from snoring, do something to fix it. You could be losing precious sleep due to your problems of snoring or sleep apnoea.
• You can minimise snoring by using a mandibular advancement device.
• To correct sleep apnoea, it’s best to visit a sleep specialist who will ascertain the cause of your apnoea and suggest treatment accordingly.

Tune yourself

Another great way to fall asleep is to give “signals” to your body that it is time to go to sleep. You can listen to calming music or take a relaxing shower before going to sleep. A warm glass of milk before bed-time is also soothing. It promotes sleep in many people. The reason is milk contains tryptophan – a natural sleep promoter.

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An estimated 45 per cent of people snore at some time, with another 25 per cent classified as chronic snorers. And it’s more common in men than women. Let’s look at the common causes of snoring.

Sleep apnoea

Snoring may not destroy sleep, but it has the potential to lead to sleep apnoea, a potentially life-threatening condition. Apnoea, in simple terms, is upper airway obstruction during sleep. It is linked with frequent awakening and daytime sleepiness. In addition, snoring is often associated with other sleep disorders, including “restless leg syndrome”, which is caused by spasm in the arms and legs during sleep.

During sleep apnoea, the snorer stops breathing for several seconds. S/he quickly breathes air again, and slides back to sleep. It is a familiar sight which most of us have witnessed, irrespective of whether we snore or not.

The why and how of it

Snoring occurs when the throat constricts, or collapses, and partly blocks the airway. What actually leads to the noise are the tongue and upper throat, or soft palate and the tonsils during breathing.

Ignorance might be bliss for the one who snores but not for the one who is compelled to hear. Experts say that snoring can reach the 80-decibel level, the level of noise produced by your home’s small, portable drilling machine in full throttle.

Struggling day and night

In cases of snoring due to sleep apnoea, breathing can halt for almost half-a-minute. If this happens, the body goes into alarm mode, as the oxygen supply gets cut off. Soon after, the heart pumps frantically in order to find oxygenated blood to flow. Following this, the heart rate also rises. This signals the brain, which, in turn, arouses the person from sleep and drives him to open the throat and “gulp” air. However, once the chain is broken, the snorer quietly slips back to sleep as if nothing ever happened.

Following a night of constant waking and sleeping, the snorer often works up a headache and struggles to stay awake through a “drowsy” day. This is no small struggle: it lays stress on the heart during the night and increases blood pressure.

Fat always makes matters worse

Snoring is more prevalent in people who are overweight. This is due to increased fatty tissues in the throat which narrow the airway. In addition to this, overweight individuals have poor muscle tone. This causes the soft palate to droop during sleep: the smaller the airway, the noisier the snoring. This is also one main reason why obese individuals are asked by their doctors to lose weight.

Exercise your snore away

Hold your upper and lower molars together, gently. Open your mouth. Press your molars as wide as you can. Don’t stretch. Repeat 10-15 times. This exercise helps strengthen your jaw muscles and opens the back of your mouth. Remember: the muscles that you “contract” in the back of your throat, during exercise, are mainly to blame for your snoring.

Professional help

When home remedies fail [see Self Help for Snoring below], seek the advice of an otolaryngologist, or ENT specialist. The specialist may first advise non-invasive orthotic devices at a dentist’s clinic. These mouthpieces pull the jaw down and forward, and open the airway wider at the base of the tongue. There are different types of mouthpieces—some hold the jaw firmly in place; some allow for a little movement. However, the downside is that orthotic devices are expensive, and they don’t seem to have a consistent record. Also, no doctor can forecast their success.

Experts say that the most common and most effective treatment for snoring/sleep apnoea is continuous positive airway pressure [CPAP], where the snorer wears an oxygen mask that gently forces air into the lungs all night long. CPAP has a high success rate. On the other hand, ENT surgeons recommend surgical treatment for snoring. Most of the surgical methods seem to do the same job of tightening or removing the soft tissue at the back of the throat, with variations. They are not comparable to CPAP as far as success rates are concerned. They also seem to only work in about 30-40 per cent of cases.

Things to avoid

• Don’t sip alcohol, or smoke, before bed-time. This aggravates snoring
• Avoid the use of tranquillisers, sleeping pills, or anti-cold, and anti-allergy medications [anti-histamines], before bed-time.

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