CPAP and Playing the Long Game

Recently I had a conversation with someone who doesn’t feel more awake when she uses CPAP.  In fact, she doesn’t feel that sleepy in the first place.  So when she was diagnosed with sleep apnea and prescribed a CPAP machine, her response was “What’s my motivation?” 

This is not uncommon.  I also remember a woman who came to see me because of a referral by her heart doctor.  She had developed AFIB (atrial fibrillation) and when I walked into the room her arms were crossed over her chest and she clearly would rather be anywhere else.  She told me with an edge in her voice that she didn’t feel sleepy at all, never had, and she slept through the night just fine.  Her husband reported snoring once in a while.  She was not overweight.  She never would have set foot in a sleep doctor’s office if it hadn’t been for the persuasion of her cardiologist.  But the connection between sleep apnea and heart problems is simply too strong to ignore, so she followed her cardiologist’s advice.

Well, that woman had an AHI of 32– which is severe sleep apnea.  I recommended treatment since it was probably connected to her AFIB.  And, left untreated, her sleep apnea would leave her vulnerable to all the other long-term health problems associated with the condition.  She was reluctant to do so, but she did.  She took home a CPAP machine and started using it.

When she came back to my clinic so I could check on her progress, I reviewed the machine’s report before I went into the exam room.  I saw that she was able to use the machine regularly.  Good mask seal.  The machine estimated an average residual AHI of 2.  In other words, her sleep apnea was fixed.  Fixing sleep apnea makes me happy.

But when I walked into the room she had her arms crossed over her chest again.  She was clearly not happy, not even neutral.  She told me that she did her part by trying the machine, but she still didn’t feel any better.  No perceived difference in her daytime functioning, memory, or mood.  And it was inconvenient and annoying.  So she was ready to be done with this machine.  Because . . . “What’s my motivation?”  

It is not well understood why some people with severe sleep apnea don’t have daytime sleepiness.  But what IS known is that the risk for long-term health problems IS related to sleep apnea severity.  There is a dose-dependent relationship.  My patient with AFIB stopped breathing once every other minute (AHI 32).  Every other minute– throughout the night– her oxygen level dipped down below normal levels.  Sleep apnea is a breathing disorder.  Your heart will suffer if it can’t get enough oxygen.  

Like brushing your teeth to avoid cavities, eating healthy to avoid weight gain, and exercising to keep your body and mind healthy, sometimes treating sleep apnea is purely about playing the long game.  

As we spent some time talking about this, my patient uncrossed her arms and began to relax.  She became more open to the idea of reframing her sleep apnea treatment this way.  She took pride in doing the necessary things to protect and maintain her health.  She began to understand that, in her case, treating her sleep apnea was a preventative measure, a case of delayed gratification.  And ignoring this problem just because she wasn’t getting short-term benefits would be inconsistent with her values.  Sometimes it’s just about the long game.