The Risks of Snoring

Snorers have always been the butt of jokes. In cartoons, their nasal roar lifts the roof off houses. In sitcoms, there's the wife who rolls her eyes at her snoring bedmate. But in reality, it's not all that funny. In fact, snoring can be a nightmare for snorers and their beleaguered partners, who may wake up several times a night to poke, prod and maybe hoist loved ones onto their sides for a little relief. It's no wonder that bleary spouses can wake up grumpy and resentful.

But the nightly racket is more than a potential relationship strain. According to the latest research, an increasingly older and heavier population may make this condition an even greater a health risk than we previously thought. For Maggie Moss-Tucker, successful treatment for a longtime snoring problem came almost by accident. One fall morning in 2005, she saw a sign at her local gym seeking snorers as volunteers for a study at Boston's Brigham & Women's Hospital. Moss-Tucker, now 56, was intrigued. She had started snoring nearly a decade earlier. "I'd tried everything to stop," she says, from sleeping upright to using nose strips or a mouth guard. But to her and her husband's dismay, nothing worked. When she signed up for the study and spent a night at a suburban Boston sleep lab, she found out why.

After reviewing her sleep patterns and oxygen levels, researchers told her that her snoring was actually an indication of something worse. She suffered from sleep apnea, a condition in which patients stop breathing repeatedly as they sleep and can wake up as many as 100 times a night—often without remembering it. That kind of revelation has led to doctors re-evaluating a condition once treated as little more than a nuisance. "In the past, snoring has been treated like a joking matter; you never talked about it with your doctor," says Dr. David Rapoport, medical director of the Sleep Disorders Center at New York University Medical Center. "But when it becomes very prominent or such that it wakes you up or interferes with breathing, it can be a problem."

Not everyone who snores regularly has sleep apnea. UCLA pulmonologist Michael Littner, who is certified in sleep medicine by the American Board of Internal Medicine, estimates 50 to 60 percent of those with habitual loud snoring have it. But research is finding that sleep apnea is not the only health condition associated with snoring. The sound occurs when the flow of air from the mouth or nose to the lungs makes tissues in the airway vibrate, usually because of an obstruction or a narrowing of the airway. The more the airway closes or is blocked, the harder the body has to work to push air, which puts pressure on the heart. That's why, over time, loud snoring can lead to high blood pressure, says Rapoport's colleague, Joyce Walsleben, past director of the New York University sleep center. "People who are just snorers have higher incidence of stroke and cardiovascular disorders."

Sleep apnea, in which the airway becomes blocked or, less often, the brain fails to properly control breathing during sleeping, can be viewed as one extreme of the snoring spectrum. Soft or sporadic snoring, which is not generally considered a health hazard, would be at the other end. As the sound and persistence of a patient's snoring grows, so do the health concerns. A study published in the March 1 issue of the journal Sleep found that loud snorers had a 40 percent greater risk than nonsnorers of suffering from high blood pressure, 34 percent greater odds of having a heart attack and a 67 percent greater chance of having a stroke.

That's a problem given the number of noisy sleepers out there. In a recent poll by the National Sleep Foundation, about one third of U.S. working adults reported snoring at least a few nights in the previous month. Snoring generally worsens with age so the rate is even higher among the elderly. And, contrary to common perceptions, it's nearly as common in women as men. Menopause appears to be a factor, as is weight. Being overweight can cause thickness in the airway tube, constricting the flow of oxygen.

Yet many who regularly snore don't realize that it could be bad for their health. The research linking hypertension, cardiac problems and loud snoring is relatively new. And though awareness of sleep apnea is growing, specialists say the condition is still vastly undertreated. Primary-care physicians don't routinely ask patients about the quality of their sleep—though that is beginning to change—and few patients think to tell their doctors that they're snoring, unless it becomes disruptive to their partner. Sleep specialists estimate that between 12 million and 18 million Americans have some form of sleep apnea but many of them, like Moss-Tucker, remain undiagnosed for years. Research from the National Sleep Foundation indicates that only half of those with sleep apnea are being treated. Since it is a progressive condition, says Michael Twery, director of the National Institutes of Health's National Center on Sleep Disorders Research, "the person who's affected is usually not aware of how severe the condition is."

Moss-Tucker remembers being drowsy during the day sometimes, but she blamed it on her busy life. When researchers at the sleep lab asked if she had ever fallen asleep while driving, she laughed initially. But then she recalled long drives during which she'd had to pull over every 45 minutes to take a cat nap to avoid dozing off at the wheel. She'd also become accustomed to taking daily 25-minute naps each afternoon. But once she was diagnosed and began using a Continuous Positive Airway Pressure (or CPAP) machine, the most common treatment for sleep apnea, she says, "My life changed."

Moss-Tucker no longer needed naps and her energy levels, mental clarity and general moods improved—so much so that she cannot imagine one night without the CPAP, a machine with a mask that attaches to the nose, mouth or both, helping to force oxygen into the airway while the patient sleeps. If it's used properly, it is nearly 100 percent effective. But CPAPs (or BiPaps, which deliver alternating levels of oxygen), which cost about $500 or more with the mask, can be cumbersome to use and the noise may be as disruptive to sleeping partners as snoring. That can be a major factor in compliance.  Despite its efficacy, estimates of overall long-term usage rates remain between 50 to 70 percent.

For snorers who don't appear to have sleep apnea, there are other measures to avoid bad nights. They include: avoiding big meals and sedating drugs like antihistamines and alcohol before bed; sleeping on one's side instead of the back; treating conditions like allergies and colds that can cause or worsen snoring, and maintaining a healthy weight.

There are also devices, like the one Moss-Tucker tried without success, which push the lower jaw forward to help keep the airway open. "They are effective in a fair number of snoring cases," says NYU's Rapoport, but he cautions that they need to be custom fitted by dentist and can be expensive if not covered by insurance.

Surgery to widen the airways or improve nasal airflow is also an option, though it too may not be covered by insurance and success rates vary. UPPP (or Uvulopalatopharngoplasty), in which a surgeon removes tissue at the back of the throat, can require a hospital stay and a long recovery; it's typically used for patients with moderate obstructive sleep apnea. But other procedures can be performed under local anesthesia in a surgeon's office, including laser-assisted uvulopalatoplasty (or LAUP), a modification of UPPP in which the surgeon uses a laser to cut the uvula. Patients who get LAUP can generally resume their normal routine almost immediately afterward, but they may require up to five treatments. Somnoplasty is another short office-based procedure; it uses low-power radiofrequency energy that reduces the volume of the soft palate tissue (located at the back of the roof of the mouth) but may require more than one session. Nasal surgery may also be recommended for those with obstructions in the nose. Another treatment is the Pillar procedure, in which three tiny inserts are injected into the soft palate to offer support. Since it's a newer procedure only approved by the FDA in August 2004, there's less long-term data. "Studies are showing it does work—but to what extent is not really known yet," says Rapoport.  With several options but no magic bullet, experts say it's important to have a full medical examination to determine the best course of action. But as long as snoring is seen as more of a joke than a risk,even that step may be too large for some.