In the Kanawha Valley, more pronounced cases of insomnia and other disorders are treated at the Thomas Sleep and Neurodiagnostic Center at Thomas Memorial Hospital in South Charleston and the CAMC Sleep Center in Charleston.
Causes of insomnia can include restless leg syndrome, medication dependency and anxiety or depression.
Other common sleep disorders include excessive daytime sleepiness, sleep apnea (breathing stops and starts while sleeping) and narcolepsy, a chronic neurological disorder disrupting the brain’s ability to control sleep-wake cycles.
Beyond the groggy discomfort and disorientation it causes, a protracted lack of regular, restful sleep can lead to increased health risks such as hypertension, heart disease and depression, according to Thomas Sleep and Neurodiagnostic Center physicians.
"We see patients in the office or we take them in the hospital or get referrals from other physicians," TSNC pulmonologist Dr. Asif Anwar said. "We interview them, consult with them and order appropriate sleep studies. They can be treated at the sleep lab here or it can be done at home. Once we read the sleep studies and have diagnoses, we can help them with the appropriate CPAP (Continuous Positive Airway Pressure) machines for other medications that may be needed in their scenarios."
TSNC Sleep Lab Director and sleep specialist Dr. Emad Kowatli said 90 percent of sleep centers in the United States are operated by pulmonologists such as Anwar and himself. "That's because pulmonology is associated with the drop in oxygen that occurs when people have sleep apnea," he explained.
Sleep apnea, Kowatli said, is a particularly prevalent sleep disorder among West Virginia residents and a contributing factor or precursor to a variety of other, more debilitating health conditions.
"The people of West Virginia are second in the nation in morbid obesity and we're second in the nation in tobacco abuse, unfortunately," he said. "And we have a lot of miners. The combination of those will cause people to run into trouble with rest at night, particularly with sleep apnea.
"Ninety percent of the time, it's caused by obesity. When there is tobacco abuse or a mining history, patients will develop COPD at the same time.
"We have to remember we need oxygen 24/7," Kowatli said. "We cannot have two or three hours of low oxygen during sleep; that can cause multiple problems. Fifty percent of people with sleep apnea have high blood pressure. Fifty percent of patients coming to the emergency room with a stroke have sleep apnea. Fifty percent of the people coming to the emergency room with a heart attack have sleep apnea."
Kowatli said sleep apnea can contribute to conditions such as diabetes mellitus and high cholesterol levels -- and risks during everyday activities.
"Sleep apnea can cause more car accidents," he said. "It's about seven times more than for normal people. It's like being a drinking driver. The reason why car accidents are common in the early morning is because people waking up aren't fresh, from sleep apnea, and fall asleep behind the wheel.
"The FAA will not let a pilot fly an airplane until we treat his sleep completely. In five states -- not in West Virginia -- it's required physicians should report a patient to the DMV if they have sleep apnea and are refusing the treatment.
"If I don't treat a patient with sleep apnea who has a stroke," he said, "most likely in six months, that patient will have another stroke. If hypertension can't be controlled by medication, it could be sleep apnea. If a patient has a heart attack, we put a stent in, and, if we didn't treat sleep apnea, the stent will be blocked in six months.
"The bottom line is: Sleep is a time for the body to rest. If I will not let somebody rest, then all of the other problems will occur. "If patients are sleeping during the day, their productivity will decrease. They cannot concentrate. Their memory will be less. They can get depression, gain more weight, so it is a bad cycle," Kowatli said.
"We call it excessive daytime sleepiness," Anwar said. "That's when you sleep throughout the day, aren't feeling refreshed in the morning or throughout the day, if you fall asleep easily after lunch and go for a siesta right away. Or if you feel sleepy when driving. For kids, it can be falling asleep in the classroom. Those things are very common."
As are minor bouts of forgetfulness spurred by inadequate sleep, he said.
"Obstructive sleep apnea is related more with being overweight or having a high Body Mass Index," Anwar said. "It happens moreso with adults than children, but there are some genetic components that can play a role. There are other factors you can modify and some you can't, like if you're born into a family whose members tend to have a higher BMI, even starting at an early age. It can occur across the age spectrum."
Anwar said modifiable behaviors to lower risk factors include eating habits and exercise.
"Obesity, overall, has been a major trend, and we're seeing a direct correlation with being overweight or having a high BMI. It's increasing exponentially throughout the world, but more in the United States. It may be geographic, with some relationship to the per-capita income of the state. I don't have exact figures, but it seems to occur more with low socio-economic status and tending to rely on fast food in your diet. Those things result in obesity and more incidents of sleep apnea. lt can differ from zip code to zip code," Anwar said.
"Weight loss is so important. Sometimes, we send patients have weight reduction surgery," Kowatli added.
Possible warning signs and wake-up calls
Anwar said some sleep behaviors can be harbingers of pending or already present ailments.
"For some patients or their spouses or sleeping partners, it can be as simple as snoring," he said. " That could be the start of it -- not that everybody who snores has sleep apnea. We should be looking at it as a primary or initial symptom. Everybody snores. If it's mild snoring that occurs during the night, that's considered OK and acceptable. If the snoring is loud enough to be heard outside of the room or the partner is disturbed, that might be a telltale sign of sleep apnea."
Sleep apnea diagnosis and treatment advances Dr. Lo’ay Al-Asadi is a pulmonary disease specialist with the CAMC Sleep Center and the director of Ohio Valley Sleep Diagnostics in Ripley. He has also maintained a private practice in sleep disorder treatment for more than 20 years in Kanawha City.
"Initially, as a clinician, you have to suspect sleep apnea," he said, noting that patients are given an eight-question survey and if they score 10 or above out of a maximum 24 possible points, it's likely they have the condition.
"We'll question the patients or, sometimes, spouses are even better to ask. Sometimes, the patients are not aware they really snore or have sleep apnea. When the partner says the patient stops breathing or is snoring, you further pursue sleep apnea as the cause," Al-Asadi said. "Once you have a clinical suspicion," he said, "you look at their medical history to see if anything supports that. We check their throat and see if they have other diseases, specifically high blood pressure or cardiovascular disease."
After that analysis, Al-Asadi said, confirmation testing is done either with a home sleep study or a sleep-attended sleep study in the onsite sleep lab.
Once a diagnosis of sleep apnea is made, "a CPAP is the first line of treatment, no matter what the severity of the sleep apnea is," he said. "There are other treatments in other situations. For someone who has mild sleep apnea, mainly when they sleep on their back, or if they're unwilling to wear a CPAP, there may be positional therapy and, definitely, weight reduction surgery will be beneficial."
Al-Asadi considers sleep clinics vital for treatment and prolonged success. "It's important to see them afterward; it's a chronic disease we have to follow up on," he explained. "I've had patients I've seen for 20-plus years. We don't necessarily do sleep studies every year, but we see how they're doing on their CPAPs."
He said some new procedures are also being considered beyond the use of CPAP apparatus.
"For patients who are not going to tolerate the CPAP, there are dental appliances and a new surgical approach will become an option.
"Some patients are sent to a dentist or oral surgeon who will fit them with a dental appliance or look at their jaws and see if any surgery there can help them. And a new surgery has come out in last four to five years called Inspire Surgery."
Al-Asadi said Inspire Surgery isn't available in West Virginia currently, but he is working with a firm to make it available to his patients. "It's like a pacemaker inserted under the skin in the chest. It can sense when the diaphragm is moving and tries to dilate muscles.That should crystallize in the next few months, and we're very excited about it coming to West Virginia."
Through Inspire Surgery, an inserted sensor sends mild stimulation to the hypoglossal nerve to prevent the tongue from blocking the airway during sleep.
A possible pandemic connection
Anwar said the social disruptions of the COVID-19 pandemic may also prove to be a contributing factor to an emergence or exacerbation of sleep disorders.
"For the past couple of years, it's had a major economic and social impact on families and kids," he said. "Sleep, eating and school and work patterns have changed significantly and there's the lack of social interaction, anxiety, depression and families who've lost loved ones or who become sick because of COVID. I think it would be interesting to find out. It probably has increased, but I don't know if there have been studies. I would guess sleep disorders have increased, like how other health conditions, such as the worsening of asthma and cancer, or if it's lack of access [to treatment] or other factors that have contributed to it."
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