Coincidence or Science?
Today I wanted to discuss nocturnal bathroom breaks and it’s correlation to sleep apnea as well as some fundamentals as to why we seek therapy. I'll discuss some major points about sleep apnea and I will let you conclude, along with a link to a scholarly study, if it is a coincidence or science. Lets get started..
“I go to the bathroom throughout the night, isn't that normal? Everyone does it”
I may have said in the past or in a previous appointment that this is my absolute favorite part of my job - educating and proving the denial (if any) that sleep apnea, whatever degree of it, can and does affect bathroom break frequency. I love this because I have seen MANY different situations where people thought “that is how it is” or “I’m just getting old” when it doesn’t have to be like that!
I have even improved the quality of sleep, and overall quality of life for a previous patient of mine that thought sleep was what it was because the patient had a permanent catheter in place with very frequent uncontrolled urination at night (about 5-7 per night). I still remember him and his wife at the appointment looking at me while discussing his Home Sleep Apnea Test reviewing the diagnosis of moderate sleep apnea. They were convinced CPAP would not work. His exact words were “but I’ve been getting up 5-7 times per night and it’s been going on for all my life since my 20s, I really don't think it will work but we'll see”. I kindly asked them to believe me, that I was not playing any voodoo tricks or giving “sales pitch” rather just informing them on how physiology works. 2 weeks later after the initial struggles with CPAP were dealt with, the patient called me and said “I can’t believe this. I only wake up once now. You were right! I can't believe it.”. Needless to say, he has been "happy" on therapy ever since.
So how can sleep be affecting bathroom breaks? Glad you asked!
To fully understand the physiology behind it we need to go back to some basics.
We know that sleep apnea is a cessation, or partial cessation in breathing. This stoppage in breathing can affect oxygen levels and most importantly it interrupts the sleep cycle you are in to try to protect your vital organs from additional physical stress. You may not directly notice this, ever, which is why we perform sleep tests at the sleep lab and home sleep tests as well for diagnosis.
If our breathing and oxygen levels are getting affected nocturnally, rest assured there is a long molecular physiological response to the increased stress. One of the primary driving factors is release of adrenaline (nor-epinephrine) initiating the Fight or Flight response. The release of adrenaline results in an increase in heart rate, increase in blood pressure, release of glucose, inhibition metabolic hormones release and a shift from deeper restorative stages of sleep (stage 3 & REM) to lighter stages of sleep… Now, lets break it down:
Heart rate and Hypertension
- Situationally increased blood pressure due to physiological stress. When blood pressure is elevated, the heart muscles (myocardial fibers) need to contract much harder to overcome the pressure in the arteries. Remember the old 120/80mmHg for normal blood pressure? The top number is the Systolic pressure (pressure exerted to the arteries during every contraction of the heart, representing ⅓ of the mean arterial pressure) and the bottom number is Diastolic pressure (the pressure inside the arteries while the heart is relaxed, representing ⅔ of the MAP).
- With increased blood pressure, the heart may have a harder time overcoming the increased diastolic pressure resulting in some stretching of the myocardial muscles, specifically the atrial muscles (top 2 chambers of the heart that allow blood flow to enter the ventricles). This causes the hormone Atrial Nautretic Peptide (ANP) to be released in response to atrial stretch.
Why is ANP significant?
- ANP is a vital hormone that is released in response to hypervolemia (too much fluid in the arteries) or due to atrial stretching.
- ANP assists in fluid control inside the arteries by dilating renal arteries and promoting blood flow to the kidneys. The kidneys enter a stage of overdrive on a nightly basis to try to eliminate fluid as a response to the ANP hormone.
- ANP also inhibits the release of the hormone called anti-diuretic hormone (ADH) that is normally released nightly to prevent us from getting up throughout the night.
- Interestingly, patients that suffer from Congestive Heart Failure will always have the cardiac markers such as the ANP elevated when assessing their heart.
Coincidence or health science?
Find out more here in this study about ANP Hormone & sleep.
- With every fight or flight response, the body not only needs oxygen and blood flow, but it needs the essential energy source to get through the stressor.
- Glucose is the body’s priority element delivering “energy” to muscle groups.
- Because we are sleeping and not exerting ourselves, glucose is left in the extracellular blood plasma resulting in a higher glucose level in the morning and in many cases - loss of appetite in the morning. Think of it this way, if your body already thinks it has all the sugar it needs to function, why would the body send a signal to consume more food? Also, if you haven’t eaten anything in over 8 hours, why would the blood sugar levels be high?
- The consistently high sugar levels will eventually break down your body’s ability to control blood sugar, leading to poor glucose control leading to pre-diabetic stages.
- I cannot begin to say how many lives I have changed for the better once this was absorbed and my patients made sense of what is happening and why we are doing what we are doing (CPAP).
Inhibition of metabolizing hormones
- Believe it or not, sleep has a major direct affect on the way and effectiveness we metabolize food.
- Hormones such as Leptin, Ghrelin, Growth Hormone and cortisol all play a role in the control of appetite, metabolism rate, and activity level.
- These hormones tend to be released during the Slow-Wave portions of sleep (Deep stages of sleep). Now, if someone has breathing issues and oxygen dips during sleep, remember what happens to the restorative stages of sleep? I bet you got it. We don’t go through them nearly as much, if at all. So what would happen to the ability of losing weight? or ability to control hunger?
- When people are overweight, it is TOO easy to say “just lose some weight”. What we don’t know, or at times just overlook, is what is going on microscopically that can mean a break it or make it for the individual. This is in no way to say that fixing sleep will shed off weight, rather with an on-going diet change and restorative sleep controlling metabolizing hormones, it will make losing weight that much easier as long as you follow your plans.
If we do some napkin math, this would mean that roughly ¼ to ⅓ of our lives we spend sleeping. If there are physiological stressors, it will start resonating throughout the day through any symptoms such as high blood pressure, insomnia, diabetes, fatigue, morning headaches, restless leg, and so much more.
Remember, not everyone will experience the same symptoms so it is always better to get a global approach when evaluating sleep and look at things from all sides by a sleep therapist and a doctor. The worst thing one can do is live in denial and accept something that is so easily treated.
I will never, EVER say you will die in your sleep if it is left untreated nor will I say Sleep Apnea Treatment is the end-all-be-all and all is peachy afterwards. With all my patients I focus on quality of life, not longevity. Leaving OSA untreated can lead to premature, avoidable deaths and greatly reduced quality of life requiring intensive medical attention, increasing the number of medications and more. We all understand as we age it is normal for some things to start going and medications start being needed. However the list and amount of medications can greatly be reduced by a positive health plan and quality, treated sleep.
Sleep Apnea is one of the leading under diagnosed conditions affecting millions. The more awareness there is, the better outcome for people's health and less of a burden it will be in the health care system. I hope with this tad-bit of education and facts I have helped strengthen your understanding of what I do daily!
Rafael Mendonca, RRT CPSGT Manager
On behalf of Capital Home Medical & www.Capitalmedicalsupply.ca and the College of Respiratory Therapists.