A Rising Health Crisis for Service Members & Veterans: Undiagnosed Obstructive Sleep Apnea

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If you had information that could prolong the life of one (1) out of (11) eleven of your acquaintances, would you act swiftly? There is a good chance that your buddy who drinks 2-3 energy drinks a day or multiple cups of coffee may be suffering from an undiagnosed sleep disorder and may have various other illnesses that are progressing without their knowledge.

People take antidepressants prescribed by their health care provider for behavioral health issues when the underlying problem is a sleep disorder masked as a mental disorder. Some of you may have been diagnosed with PTSD and undiagnosed sleep disorders. Your healing and quality of life will not improve and will continue to decline when left untreated.

The stigma of a provider assuming a service member is hunting for a higher disability rating or a service member’s fear of becoming non-deployable has contributed to the number of undiagnosed patients.

The lack of diagnosis leads to multiple diseases that could have been prevented had the sleep disorder be recognized. The cost of treating these multiple diseases creates an unnecessary annual billion-dollar burden. This continues to impact military readiness and influence the rise in Service Members and Veteran suicides. Undiagnosed Obstructive Sleep Apnea (OSA) is a major medical issue on the rise in the military.

This article provides simple solutions and a strategy to attack this problem. Provided here are recommendations for those at all levels to address this problem. The individual, lower-level unit commanders, medical providers, hospital directors, and higher-level military and political leaders (show me the money! those that can validate and prioritize resources to address this problem).

Review links below for Departement of Health Clinical OSA Diagnosis Guidelines along with future study opportunities

Undiagnosed and untreated OSA will continue to be an influential factor contributing to the service member and Veteran’s decline in health to include the rise in suicides. This is another simple solution that takes leaders’ involvement. If all leaders reading this choose to acknowledge the impact of sleep disorders on one’s overall health, including mental illness, and take action now, we will see a reduction in suicides. However, it’s not just the suicide crisis that concerns me with undiagnosed OSA, but the multiple diseases developed as well due.

OSA is characterized by the collapse of the pharyngeal airway leading to repetitive interruption of ventilation during sleep. Diagnosis of OSA is usually made when a patient has an apnea-hypopnea index ≥5 and excessive daytime sleepiness. The estimated prevalence is about 1 in 5 adults having at least mild OSA and 1 in 15 having moderate to severe OSA.

A Look at the OSA National Data

According to Frost & Sullivan, in a study titled Hidden Health Crisis Costing America Billions, undiagnosed OSA creates a $149 billion strain on the U.S. economy. The Department of Veterans Affairs alone spends over $1 billion annually to provide medical care for diseases developed.

Service members and veterans are unaware OSA has slowly deteriorated their health. Many veterans are referred to behavioral health clinics for mental disorders when the underlying cause is OSA, insomnia, or difficulty sleeping due to musculoskeletal pain. This cost is a result of treating other diseases that developed due to undiagnosed OSA. Many service members never assume themselves as one with OSA either.

OSA Causes More Health Problems

Per 38 CFR § 4.97, Diagnostic Code 6847, OSA can be rated up to 50% disability upon retirement if found service-connected. This knowledge creates an implicit hesitation amongst primary care providers when a patient recommends possible sleep problems. Especially if the patient is close to retirement. Usually, any small amount of diagnosed PTSD allows for a linkage of service-connected OSA.

Undiagnosed OSA increases the chances of obesity, diabetes, Gastro-oesophageal reflux (GERD), cognitive decline, behavior health (anxiety, depression, stress, suicide), asthma and hypertension, atrial fibrillation, cancers, such as pancreatic, renal, a chronic kidney disease, high blood pressure, and stroke, glaucoma and dry eye.

The Economic Burden

Why is the national cost so high? Poor work productivity, accidents, both at work and driving to and from work, and wasted medical treatment, are a few other variables creating the cost. Medical providers diagnose patients with mental disorders, migraines, and treating for COVID when the underlying problem is a sleep disorder.

“Each physician should also be aware that some antidepressants may worsen or induce primary sleep disorders like restless legs syndrome, sleep bruxism, REM sleep behavior disorder, nightmares, and sleep apnea, which may result from an antidepressant-induced weight gain”
Current Psychiatrics Reports August 2017

Just the other day, I was talking with a veteran who suffers from Rheumatoid Arthritis (RA). He had received treatment from a provider new to his case. This provider wanted to refer him to behavioral health and prescribe antidepressants when the symptoms presented were due to pain-related insomnia leading to an active sympathetic nervous system. The pain disrupted a healthy sleep pattern preventing the required “rest and digest” Recently, the field of sleep medicine has identified other misdiagnosis problems.

When treating COVID patients with oxygen therapy when the underlying illness is OSA can cause unnecessary death due to the impact of oxygen therapy on patients’ cardiovascular system with OSA. Additionally, patients with OSA tend to have rapid shallow breathing due to hypoxia, which results in an acceleration of pneumonia, adding complications to patients with COVID when providers do not recognize OSA in a patient.

“Untreated OSA can affect the military mission and personal performance, as members may suffer from cognitive impairment, chronic fatigue, post-traumatic stress disorder (PTSD), and other chronic illnesses“
Medical Surveillance Monthly Report, Volume 23 Number 10, August 2016

Awareness is Needed Now

A drastic change requires political and military leaders, making this hidden epidemic a priority and demonstrating their commitment by appropriating resources to this problem. I am sure that most leaders would prioritize resources to combat the OSA epidemic if they were aware of the problem. Previously I was not aware of this issue. In conversing with many friends and co-workers, they were not aware of this problem. Some installations have closed their sleep labs to utilize the space for COVID operations. Installation construction projects supporting sleep health lack prioritization. This could be the most important thing you read this year, especially if you realize that studies have reported a 10% to 12% increase in mortality risk among those with sleep disturbances.

The first step is education and the development of an appreciation of the negative impact of OSA and its long-term effects. Creating this motivation will save lives, improve military readiness, reduce economic burden, and provide an enjoyable, pain-free life for the service member once their military service has ended. Effective sleep impacts physical and mental health. Without it, all other training can be a waste of time. There is plenty of evidence over the past 10-15 years that an aggressive approach to this problem will save billions of taxpayer dollars.

Lack of priority is evident when you see publishing dates of multiple studies on the Military Health System’s Official Website, where this problem has been highlighted for several years. How many can recall ever being a screen for sleep disorders in any of your medical appointments? Treatment at one of the Military concussion clinics is the only facility where sleep disorder screening is mandatory.

Recommendations: Take Action Now

Changes can be made now at all levels to address this problem. The recommendations listed here are not new. They have been recommended for over 10 years on the DHA website. They have yet to be prioritized, implemented, and enforced. Lack of leadership prioritization may continue. However, I hope that a few will be enlightened. At least each reading this can take personal action and determine if they suffer from OSA and improve their own lives and the lives of those around them. Over 80% of those with OSA can be treated with a Continous Positive Airway Pressure (CPAP); the few others are treated through diet or lifestyle change, nonsurgical devices, and a few require surgery.

For the Individual

The first recommendation is not to fear the consequences of being diagnosed with OSA. I had once frowned upon OSA and would never seek treatment for this problem. The fear of knowing OSA may require a CPAP machine, preventing deployability, also prevented a desire to seek medical assistance with sleep issues. This deterrent no longer exists, and a CPAP will no longer prevent a service member from deploying. In fact, the regulation requires that a battery be issued for the CPAP when deploying.

Military medical readiness has come a long way. A few years ago, an exception to the policy was required for a service member to deploy with a CPAP machine. Additionally, medical devices such as a Mandibular Advancement Device (MAD) used to bring the jaw forward and tongue stabilizers opening up the obstruction have made OSA treatable in deployed settings. The chances of a medical board have greatly reduced when the OSA can be resolved.

The following guidelines and self-diagnosis tools and analysis criteria will provide enough information to determine if you should seek further medical attention for OSA. According to Dr. Meagan Rizzo, chief of sleep medicine at the Walter Reed National Military Medical Center in Bethesda, Maryland, “Home sleep tests can be good at picking up moderate and severe obstructive sleep apnea in high-risk patients,” this is the first step of taking control of your own sleep health.

Do you have any of the following symptoms below? You can also download a Department of Health Agency diagnosis smart card and click the download the link below.

US Army OSA Diagnosis Guide Download

Headaches
Sleepiness
Loud, bothersome snoring
Nightly gasping/choking
Difficulty initiating sleep, difficulty maintaining sleep, or early-morning awakenings
Do you have anxiety, bruxism, restless leg syndrome

OSA Self-Assessment Tools for the Individual Use at Home

Take the Epworth Sleepiness Scale; scoring >10 points on the Epworth Sleepiness Scale is a sign of a sleep disorder. Click on this link or download the excel version below. This tool is common in sleep medicine.

Epworth sleep scale excel worksheet.Download

Left, standard Pulse Oximeter in
medical clinics, right, infrared light on home Pulse Oximeter ring.

A measurement below 95% SpO2 is a sign of possible OSA. SpO2, also known as oxygen saturation, is a measurement to verify an accurate amount of oxygen is present in the bloodstream for the body to function properly. This is done through infrared wavelengths utilizing a SpO2 device. You have placed this device on your finger by a medical provider when your vitals are taken; spo2 measurement was invented in 1972 by Takuo Aoyagi. Home medicine SpO2 devices can be used to diagnose OSA and confirm an obstruction requiring medical treatment.

I have purchased a few different versions. As seen above on the left, the ring pulse oximeter provides accurate data throughout the night, is downloaded to an app, and costs $189. The product on the right is cheaper ($28), will require medical tape to secure it to your finger while sleeping, and has only 5 hrs of battery. There are many products online that can assist with verifying your SpO2. For myself, it was worth the investment. I average 92% SpO2 nightly and drop below 85% for a few seconds each night. Measure blood oxygen saturation using at-home Pulse Oximeters is a great method to diagnose OSA. A variety of studies have compared its efficacy to in-depth tests conducted in a sleep lab. Research has demonstrated effectiveness for home OSA diagnosis using oximetry. Gumb et al. stated, in a study comparing Apnea Risk Evaluation System (ARES™, multiple signals plus forehead reflectance oximetry) and the Nonin WristOx2™,

Another self-assessment technique is to Verify the frequency of snoring. Snoring can be a sign of OSA but doesn’t always mean an obstruction preventing the required greater than 95% SpO2. If your SpO2 is above 95%, then more than likely, the only one suffering from a sleep disturbance is those attempting to sleep near you. Multiple mobile phone applications improve sleep quality. The Snorelab is an app that you can use to determine the frequency of snoring.

After this individual self-assessment, if you have scored greater than 10 points on the Epworth Sleepiness Scale and have less than 95% SpO2, I urge you to push your medical provider to recommend further testing. If you have other respiratory health issues such as asthma or Chronic Obstructive Pulmonary Disease COPD, a SpO2 below 95% may be normal. The key to verifying the accuracy of these SpO2 devices is reading effectiveness. Most devices have a measurement reading to identify if sensor contact is receiving the correct reading.

Individual Treatment

The following are a few tips for the individual to now implement to improve your sleep quality while awaiting a medical practitioner’s diagnosis.

If your BMI is above 35 first tip is to change your diet now and lose weight.
Stop smoking if you are a smoker.
Download The Snorelab app and journal your snoring intensity and daily fatigue
Most have more OSA issues sleeping on their back. Using a fanny pack, place tennis balls in the pack and position them in your mid-back, making it uncomfortable to sleep on your back.
Use Sleep Cycle apps such as the ones found at this link.
No caffeine, if needed, no caffeine after mid-day.

Lower Level Unit Commanders

Company / Troop/ Battery, Battalion/ Squadron Commanders can take action now to save lives and taxpayer dollars. Medics at unit aid stations should screen service members for OSA when a service member presents OSA symptoms. At this level, Medics would be executing initial field triage to confirm/recommend further evaluation by the patient’s primary care provider, especially when the service member displays symptoms of a mental disorder.

The Official Website of Military Health, Developed by DHA, has provided multiple smart cards to assist medical providers at all levels in looking for and diagnose sleep disorders. The VA/DOD Clinician flow chart for sleep disorder diagnosis is another great product that has been around for over 10 years. Units should purchase Home Sleep Disturbances Test kits and retain them at the unit aid stations for unit-level initial triage such as Pulse Oximeter; additionally, apps such as Snore Lab to aid in early diagnosis by primary care providers.

I mentioned some cost-effective devices for individuals; at the unit level, there are a few home test systems that are over $500 that may be more beneficial for unit purchase to support aid station screening, such as Apnea Risk Evaluation System (ARES™, multiple signals plus forehead reflectance oximetry) and the Nonin WristOx2™. As I mentioned above, multiple studies are comparing the effectiveness of these devices.

Leaders should also include in their annual training program, initial triage of OSA training for 68 Series and 18D up through specialty practitioners; training options for screening OSA such as those developed by the Defense and Veterans Brain Injury Center. Additionally, leaders can include short mandatory self-directed training to all service members via a YouTube video providing awareness of OSA, use of caffeine, nicotine, etc., during other annual mandated training.

Ending the stigma as well will provide more awareness. It’s no longer a career-ending decision when placed on a CPAP, but undiagnosed can lead to a career-ending medical separation board. Informing service members of the important role that sleep plays and the impact of poor sleep on the body will greatly address the problem.

For the Primary Care Manager

To those in the medical field, I implore you to read to understand what I’m saying, do not read, respond, apply some deductive reasoning coupled with emotional intelligence, then infuse a bit of medical reflective journaling. A simple solution that will reduce the number of suicides lies right in front of you. Some of the greatest innovative ideas are perceived by the non-experts, as they are more willing to ask why and not be influenced by the blinders controlling experts in this field.

General Practitioners have difficulty determining the underlying cause of a patient’s symptoms, ensuring that the care is correct. I’ve seen in the eye rolls of providers when they hear the phrase: “I looked up online.” Our brain’s natural tendency is to question when we are questioned. Growth and innovation occur when we question our perceptions.

The $149 Billion consequence of undiagnosed OSA is due to a lack of education/awareness and false assumed perceptions of patient symptoms. According to Risa Nakase-Richardson, a neuropsychologist and scientific research director at the Tampa Defense and Veterans Brain Injury Center, “Medical students get a one-hour lecture on sleep for their entire medical training.” Training must be augmented at the unit level. DHA has been aggressively attempting to educate with easy-to-use clinical guidance, yet they appear not to reach the user level.

DoD Clinical Practice Guidelines (GPCs) clearly articulate what needs to happen. However, it does not appear to be implemented at this time. Medical providers need to learn how to look for symptoms of OSA during screening properly. DoD guidelines for medical practitioners provide in detail the steps for OSA screening. The DHA tools have been available over the past ten years but appear not to be implemented.

Implementation will make this change. An article in the Journal of Clinical Sleep Medicine provides an excellent guideline on improving sleep medicine quality.

For the Behavioral Health Provider

Many symptoms of depression and obstructive sleep apnea are similar; hence, one reason for the OSA being missed in screening. Read a story of the impacts of undiagnosed OSA. Behavior health is great for everyone; I greatly enjoy it and have grown immensely. However, some primary health care providers refer patients to behavioral health as they assume their symptoms are caused by a mental disorder when the root problem is an overactive sympathetic nervous system from poor sleep caused by OSA.

I highly recommend all patients treated with Post Traumatic Stress Disorder (PTSD) be evaluated for sleep disorders. The Journal of Sleep Medicine published a study that looks at the DSM-IV, diagnosis, and sleep disorders. This study is a good read and will generate thought for behavioral health providers to influence patients’ approaches to presenting these symptoms. Therapists typically ask their patients if they want to try medication and sometimes recommend it in conjunction with psychotherapy. Care must be taken to ensure that a sleep order has been ruled out to avoid exposing patients to medication that is not needed, especially as most antidepressants increase fatigue.

In the American Journal of Psychiatry, Dr. David V. Braitman states, “Screening for symptoms associated with sleep apnea can easily be woven with the discussion of symptoms normally reviewed in a psychiatric interview.” The biggest mistake that can be made is not the application of psychotherapy. Everyone can use some psychotherapy, but exposure to medications that are not needed can create more damage or increase the destructive process of OSA.

Hospital Directors and Military Leaders

As to why the military medical community has yet to place importance on these problems is a mystery. Environmental factors weigh in on this as well. The COVID-19 epidemic has influenced hospital directors to close sleep clinics to make room for COVID-19 operations. Medical providers have a difficult job and often assume wrong, key symptoms, leading to a misdiagnosis that begins the downfall of a service member’s physical and mental health.

Leaders at all levels, I ask that you think about OSA when reflecting on suicides. This is an easy win as we deal with the rise in suicides as OSA contributes to this epidemic. Leaders must first change their perception of OSA to influence organizational change. I ask all leaders to first apply my recommendations for the individual. We need excellent leaders to continue to be healthy and lead our great nations.

This systemic problem is not new, it has constantly been highlighted for more than the past 10 years, and we have yet to see any changes great enough to impact. Frost and Sullivan emphasized this in their 2015 study published in the American Academy of Sleep Medicine (AASM), a “nonappreciation of the seriousness of this illness exists,” OSA not only weighs an enormous economic burden on our nation but also results in unnecessary deaths and early medical discharge from service. This nonappreciation occurs at all levels. Lower-level leaders can make changes today.

Everyone can learn how to self-assess OSA and request medical attention when concerned about their sleep, and when a medical provider fails to assist you, find another one. This is your life, not theirs.

If political and military leaders are looking for innovative ways to prolong the life of its service members who have dedicated their lives to our country, addressing the problem of undiagnosed OSA is an easy win. I desire to seek change within the military and amongst my family and friends. It is an easy, quick solution that requires awareness and military leadership emphasis.

If emphasis and prioritization by military and political leadership cannot be obtained, we can make a change at the lower and individual levels. We are in a resource-constrained environment and must find innovative ways to achieve our objectives. Frost & Sullivan estimates a $100 billion savings if OSA is diagnosed. We can start this now at the individual and small unit levels. I implore everyone who is reading this to apply the individual recommendations at least. Company, Troop, Battery Commanders can implement action now using the unit purchase of home OSA kits and sign them out to those who present symptoms to serve as a field evaluation confirming a diagnosis by the primary care provider is needed.

My recommendations are based on personal experience and research. My sources are listed throughout this article. I will happily talk more about this problem with anyone who has questions.