Sleep apnea is common in stroke survivors. Recent studies suggest that as many as 65% of stroke sufferers experience some degree of sleep apnea. According to a leading researcher and physician in the field of sleep-disordered breathing, Mark E. Dyken, MD, University of Iowa, this high rate of sleep apnea in stroke survivors “requires aggressive assessment.” Because data suggest that rehabilitation outcomes may be worse in stroke sufferers who have sleep apnea, it is of particular importance to identify it.

Overview of sleep apnea

Normally during sleep the muscles which control the tongue and soft palate hold the airway open. As these muscles relax, the airway becomes narrower, which can cause snoring and breathing difficulties. In some cases, these muscles relax too much, which causes the airway to become completely blocked, preventing any airflow. Once the airway has closed and no breathing is occurring (apnea), the brain realizes that there is a lack of oxygen and alerts the body to wake up. Though the sufferer is often not aware of it, this cycle can occur several hundreds of times each night, severely disrupting sleep. This is sleep apnea.

The impact of sleep apnea on health

Each time an apnea ends, there is a surge in heart rate and blood pressure. These changes, as well as drops in oxygen levels that result from sleep apnea, have been identified in the progression of high blood pressure, heart disease, congestive heart failure, transient ischemic attacks (TIAs), and stroke.

Treating sleep apnea

Sleep apnea is commonly treated with positive airway pressure (PAP). PAP is administered via a nasal mask that is connected to a flow generator, or blower. The flow generator delivers a lightly pressurized stream of air that supports the muscles in the throat during sleep. There are many types of flow generators, but for stroke survivors with sleep apnea, the best type of PAP is automatic. Automatic positive airway pressure devices adjust the strength of air that they blow throughout the night, to provide the least amount of air necessary to support the airway breath by breath. In a sense, automatic PAP devices provide customized treatment based on the individual needs of each unique patient.

Caring for stroke survivors with sleep apnea

For stroke survivors, this customized treatment is especially important. Stroke can affect the severity of sleep apnea, and as stroke survivors recover, the amount of airway pressure required to treat them may change. Automatic PAP will adjust to meet those changes. Additionally, most patients find automatic PAP more comfortable than other types of treatment. In the stroke population, comfort is a key factor of success.

For the stroke survivor who is new to positive airway pressure, adjusting to sleeping with a nasal mask and feeling the sensation of positive airway pressure will require a period of adjustment. It is crucial that an experienced sleep technician or nurse is present to help the patient in the initial stages of sleep apnea treatment. Even though PAP is a very simple type of therapy, practical problems may arise. Because stroke will often leave the survivor with physical and/or mental deficits, patients being treated for sleep apnea may need assistance putting on their nasal mask or reapplying it during the night. Also, if the stroke survivor experienced damage to areas of the brain that affect memory, they may need continual reminders of the importance of using the PAP device. The success of long-term, effective treatment will depend on how well these problems are managed in the first few weeks of treatment. Medical support, in addition to encouragement and reinforcement from stroke caregivers, will improve the patient’s acceptance of PAP.

Whether sleep apnea was diagnosed before the stroke, during stroke rehabilitation, or after discharge, caring for a stroke survivor with sleep apnea requires support from everyone involved in the care process. In some cases, stroke survivors may not feel any physical or emotional benefits from treatment, despite objective evidence of improvement. It is not uncommon for the consequences of a stroke to overshadow the relief of sleep apnea symptoms. Educating the patient and family about the nature and consequences of sleep apnea during the first few weeks of treatment after a stroke is vital. The caregivers and family members of the stroke survivor should all be informed that the benefits of sleep apnea treatment, including reduced risk of a second stroke, are worth the adjustment time. Clearly outlining treatment goals will help keep the entire care team focused on stroke recovery.

Although treating sleep apnea in stroke patients may require additional effort for caregivers, experts such as Professor of Neurology, Antonio Culebras, MD, Syracuse University agree that “application of positive pressure breathing treatment may improve the rehabilitation potential of patients post-stroke.”

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