BLOG: Look for connection between sleep apnea, concussion
As someone who spent more than 25 years working with veterans in the VA health care system, I saw many patients with traumatic brain injury and many with sleep apnea.
The two conditions are more interrelated than you might think, with each increasing the risk for the other.
For example, sleep apnea is a significant contributor to daytime sleepiness that can cause motor vehicle accidents, falls and other accidents related to inattention to one’s surroundings. Poor sleep quality is also associated with cognitive loss, impaired decision making and symptoms of depression — all of which can play a role in both traumatic brain injury (TBI) risk and the speed of recovery. People with sleep apnea who then sustain a concussion may struggle to recover, because sleep apnea reduces oxygen and blood flow to the brain. This is detrimental at any time, but especially for a brain that needs to heal from a TBI.
It’s also possible that someone who has suffered from a brain injury may experience new problems with sleep, including sleep apnea. In a recently published retrospective study of 51 people with post-concussion syndrome (PCS) who underwent a comprehensive sleep study, 78% were diagnosed with sleep apnea (Santos et al.). While it isn’t entirely clear that concussion caused their sleep apnea, the participants with sleep apnea were mostly younger than 65 years, just as likely to be women as men and had similar BMI as those without sleep apnea. In other words, they didn’t fit the typical sleep apnea profile of an overweight, older man.
The most common form of sleep apnea, obstructive sleep apnea, is caused by a physical blockage or collapse of the upper airway that interrupts breathing during sleep, and these features are certainly most common among older men with large necks who snore heavily.
Central sleep apnea is less well known. Unlike the obstructive form, it is caused by a dysfunction in the brain centers that regulate sleep and breathing, which could certainly be affected by a TBI. Central sleep apnea can occur in people of any age, fitness level or sex and may not be responsive to typical treatments (ie, a CPAP machine).
Figuring out which came first — the concussion or the sleep apnea — can be difficult. People who don’t get enough sleep already exhibit some of the symptoms of PCS even when they don’t have a concussion (Caccese et al.), making it difficult to tease out which symptoms are pre-existing vs. related to the concussion in patients who have both. And, unfortunately, when patients have a multitude of symptoms after TBI, fixing their “snoring problem” can seem like a low priority.
As front-line care providers who specialize in the eyes, doctors of optometry have a unique window into many aspects of systemic health — and sleep is absolutely fundamental to good health. A variety of ocular conditions, including floppy eyelid syndrome, ischemic optic neuropathy, generalized swelling of the optic nerve and central serous retinopathy, have been associated with sleep apnea. If you see these signs, ask about snoring and daytime sleepiness and encourage your patients who answer affirmatively to follow up on a diagnosis and treatment for sleep apnea. It could be lifesaving.
- Caccese JB, et al. Sports Medicine. 2021;doi:10.1007/s40279-020-01415-4.
- Santos A, et al. J Clin Med. 2020;doi:10.3390/jcm9030691.
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Dorothy L. Hitchmoth, OD, FAAO, is a doctor, professor, lecturer and writer. She retired from her position as chief of optometry and director of optometric residency at the department of Veterans Affairs Hospital but continues to see patients in her private practice in New London, N.H. She served in many leadership roles for the American Optometric Association and was named the Advocate of the Year in 2017. She serves on the Ocular Nutrition and Wellness Society Board, the board of trustees for the New England College of Optometry and the board of Future in Sight. She is also a business consultant for Zeiss Meditec Global and several other health care companies.
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