For our next case study, we present a 53-year-old woman with a BMI of 24.4 who was referred for an overnight PSG to test for sleep apnea and purchased Wesper to evaluate her sleep while awaiting her study. Her primary complaint was frequent, prolonged awakenings every night, with difficulty falling back asleep.

The data showed nightly snoring, with an average snoring time across four tests making up 24.4% of her total sleep time. Two out of 4 tests showed her snoring, the percentage at >35%, demonstrating nightly snoring that occurred for a significant amount of sleep time. The review of her respiratory metrics did not reveal a significant increase in breathing events.

However, she has several poor sleep hygiene habits. The user confirmed her chronic nightly snoring, daytime sleepiness, and frequent awakenings, but said she didn't have other classic symptoms. The Wesper expert revealed that she has a mix of chronic labored snoring and maintenance insomnia, with her inability to fall back to sleep within a reasonable time consistent with insomnia induced by menopause. The user qualifies for insomnia due to her frequent, prolonged awakenings.

Her snoring and potential airway resistance are likely causing at least some of her awakenings. Treatments such as hormone therapy and sleep coaching can dramatically reduce insomnia and improve sleep.

Background 

I present a 53-year-old woman with a BMI of 24.4 with a history of snoring and poor sleep quality. Her primary complaint is frequent prolonged awakenings every night, with difficulty falling back to sleep. She has been referred for an overnight PSG to test for sleep apnea and purchased Wesper to evaluate her sleep while she awaits her study. 

Explanation of metrics: 

Breathing events—Moments of increased respiratory effort, which include reduced airflow and prolonged breathing stoppages. 

Snoring Percentage - The percentage of time the user was snoring during the test.  

Total sleep time - Total accumulation of sleep in minutes. 

Sleep efficiency - The percentage of time asleep during the testing period. 

Awakenings - The total number of awakenings during the testing period. 

Findings 

The user completed four Wesper tests without the use of any medications or therapies. Her primary interest was to identify if she was at risk for sleep apnea and to see if there was a correlation between her breathing and mid-sleep awakenings. 

The data clearly showed nightly snoring, with her average snoring time across 4 tests making up 24.4% of her total sleep time. Two out of 4 tests showed her snoring, the percentage at >35%, demonstrating nightly snoring that occurred for a significant amount of sleep time. Upon listening to an audio sample of her snoring, it was clear that her snoring was both loud and labored. The frequency of her snoring and the intensity indicated that her snoring was chronic and may be correlated to sleep-disordered breathing. There did not appear to be a positional aspect to her snoring and she was found to consistently snore while in supine, prone, and side sleeping positions. 

Interestingly, a review of her respiratory metrics did not reveal a significant increase in breathing events. Her average score across four tests was 4 breathing events per hour of sleep on average, which is within the normal range. This includes a score of 4 breathing events on average per hour when her snoring was detected at >35%. 

While the breathing event metric is not equivalent to apneas and hypopneas, there is a correlation between the severity of breathing events and the severity of sleep apnea. For example, the higher the average breathing event score is, the more likely it will be for a user to go on to be diagnosed with OSA. Considering the consistency and intensity of her snoring, it was surprising to see that her breathing event score was relatively low.

Next, her sleep data showed many issues with her sleep quality. First, her average total sleep time over 4 tests was 356 minutes (approximately 6 hours), which is lower than recommended for an adult. Additionally, the average number of mid-sleep awakenings was 12.75 (man 17), which is extremely high compared to 0-4 short awakenings for a healthy individual. 3 out of 4 tests showed prolonged nighttime awakenings that lasted >60 minutes and occurred during both the first half and second half of the night. This resulted in an average sleep efficiency of 81%, which is poor compared to healthy individuals. 

Meeting With the Wesper Sleep Expert 

During the consultation with the Wesper Expert, the user confirmed her chronic nightly snoring, daytime sleepiness, and frequent awakenings, but said she didn’t have other classic symptoms. When probed, she reported that she was able to fall asleep normally but frequently woke up around the same time nightly, and it usually took at least an hour or more to fall back to sleep. This pattern is more associated with maintenance insomnia than sleep apnea. Her insomnia only appeared during menopause and has continued into post-menopause. Probing by the sleep expert revealed that she has several poor sleep hygiene habits. These include an inconsistent sleep schedule, sleeping with a young child in bed, using electronic devices before going to sleep, and tossing and turning in bed when unable to fall back asleep after awakening.

The user revealed that her snoring has been a present for over a decade, and she has never tried treatments, including over the counter remedies like nasal dilators. An ENT previously identified that she had a deviated septum and this may be contributing to her snoring. 

Conclusion 

Wesper revealed that the user has a mix of chronic labored snoring and maintenance insomnia, however, there wasn’t sufficient evidence to conclude if she was at risk for obstructive sleep apnea. Her snoring with minimal breathing events may suggest other categories of sleep disorder breathing like Upper Airway Resistance Syndrome (UARS) or Respiratory effort- related arousal (RERA) [1]. It was therefore suggested by the Wesper sleep expert that she confirm that her PSG will be also be testing for these disorders. Regardless, chronic snoring alone negatively impacts sleep quality and can cause many similar symptoms to sleep apnea, such as excessive daytime sleepiness, fatigue, brain fog, restless, light sleep, sore throat/dry mouth, hypertension and cardiovascular disease [2]. 

While her primary reason for using Wesper was to investigate her respiration, the user was surprised to learn that she qualifies for insomnia due to her frequent, prolonged awakenings. It is likely that her snoring and potential airway resistance is causing at least some of her awakenings, however her inability to fall back to sleep within a reasonable time is consistent with insomnia induced by menopause.

Sleep disturbances like insomnia are extremely common in women going though menopause (35%) and can continue after menopause (60%). Therefore, treatments such as hormone therapy and sleep coaching can dramatically reduce insomnia and improve sleep quality. The Wesper sleep expert advised the user to report her insomnia to her OB\Gyn to discuss options. Additionally, the expert advised the user on how to improve her poor sleep hygiene, especially the importance of getting on a consistent sleep schedule.

References:

1. https://www.webmd.com/sleep-disorders/upper-airway-resistance-syndrome-uars
2. https://pubmed.ncbi.nlm.nih.gov/10676674/
3. https://www.health.harvard.edu/blog/menopause-and-insomnia-could-a-low-gi-diet-help-2020011718710#:~:text=Sleep%20disturbances%20such%20as%20insomnia,%25%20to%2060%25%20after%20menopause