VA NY Harbor Health Care System
Sleep Disorders: Another Deadly Threat to Returning Veterans
Last week, Joseph Jones, 43, nearly killed himself while driving home from his job as a welder for the Army. He fell asleep while barreling down route 9A from Camp Smith in upstate New York back to his home in Astoria, Queens, a 52-mile journey.
"I literally hit the concrete barrier but I woke up in time enough to turn the wheel," says Jones. Turning the music up is his strategy to avoid drowsiness, but still, Jones says he falls asleep while driving, "like everyday". Jones was able to avoid an accident, but this close call scared him. "I don’t want to kill nobody, and I definitely don’t want to kill myself," he says.
Sleep disorders, like the sleep apnea that makes Jones susceptible to falling asleep without warning almost any time of day, must be added to the list of maladies affecting returning Veterans as they make the adjustment back to civilian life.
The problems are so common that the Veterans Administration's New York Harbor Healthcare System has opened a state-of-the-art sleep center at its Brooklyn Campus in Dyker Heights. The hospital sits on the edge of Fort Hamilton, which is the only active military base in New York City.
This four-bed facility allows veteran patients to come and spend the night so that doctors can diagnose their sleeping problems. Before the Brooklyn VA Hospital had its own Sleep Center it had a contract with Bellevue Hospital to use their sleep center. Patients had a long wait for sleep studies, sometimes over three months.
Dr. Shawn Knapik, the Sleep Center Director, says that while they see a wide range of sleep problems in veterans, 90 percent of patients are dealing with some form of sleep apnea. Congress asked the Department of Veterans Affairs to pay closer attention to sleep apnea among veterans in 2007. According the US Department of Veterans Affairs, the number of veterans receiving disability benefits for sleep apnea has increased by 61 percent in the past two years.
Dr. Knapik says the Sleep Center started as a proposal three years ago, "It was really based on a need for our Veteran patients. [Sleep apnea] is a very common problem and it may be even more common in our Veteran populations," he says, "We now see 10-12 new referrals a week for patients suspected of having Obstructive Sleep Apnea (OSA)."
An apnea is defined as a cessation of breathing for ten seconds or more, which causes sleep deprivation and lack of oxygen. It can be exacerbated by drinking and weight gain, which are both common among returning vets. Those suffering from sleep apnea experience unexplained fatigue and excessive daytime sleepiness. It is life threatening, because untreated sleep apnea can cause damage to the heart, and it increases the risk of stroke, depression, diabetes and high blood pressure.
"The connection to veterans is that OSA afflicts men more frequently than women, especially those who are in middle age and moving from an active to a sedentary life," says Dr. Mohammad Al-Ajam, a sleep medicine specialist at the Brooklyn VA. The large build of many veterans predispose them to sleep apnea, and weight gain, particularly in the neck area, can increase the risk.
Sleep apnea in combination with Post Traumatic Stress Disorder (PTSD) is an even more deadly. "The actual obstruction of the airway is not related to PTSD, but PTSD causes fragmented sleep. So when you have PTSD and OSA together your really in trouble,"says Dr. Al-Ajam.
Dr. Al-Ajam says that part of what these veterans experience in war, such as "sleep deprivation" and "exposure to chemical and to the dust" could be factors, but he adds, We don’t have a cause and effect linkage yet."
Jones was first diagnosed with OSA last year. He has an appointment to stay overnight at this lab in January in order to have a comprehensive sleep study completed. Jones says he first became aware that something was wrong in 2005 after he returned from Iraq. He said his then wife said that he would stop breathing periodically during the night and that he sounded like "a bear sleeping in a cave".
Jones' loud snoring comes from an obstruction in his upper airway due to the narrow architecture of his throat. As his body relaxes in sleep, he literally starts choking himself. Dr. Al-Ajam says that these choking episodes keep the patient from ever reaching a deep level of sleep, "Your brain has to go to back to shallow stages to give orders to the airway to open so you can take a breath," says Dr. Al-Ajam.
The interrupted sleep at night translates into extreme fatigue and sleepiness during the day. Jeffrey Hamilton, 44, a Veteran of the Army, says he thought he had some kind of fatigue syndrome, "I just had no energy compared to a couple of years ago. I got to the point where I used to fall asleep at the red light."
His primary care physician recommended he go to the Sleep Center to be tested for OSA, "They had asked me about symptoms, and I just mentioned that my wife says that since I got back from Korea in 2006 she noticed that I snored really loud and stopped breathing a lot."
Hamilton is being fitted for a breathing mask, called a CPAP. This device carries a stream of compressed air pressure to the windpipe of the sleeper, opening up their throat and allowing unobstructed breathing.
The CPAP mask is the most common treatment for people suffering from sleep apnea, Dr. Knapik says, and it is very effective, "They look brighter. In some cases it is the first time in years that they got good rest. They feel like their whole life has changed."
The science of sleep has developed throughout the past century, and as technology improved, so has the recording of sleep patterns. The Sleep Center has a Polysomnography room, which makes a record of a person’s sleep functions, including brain activity, eye movement, heartbeat, and oxygen level. The screens that record all this information have a section that allows physicians and technicians to highlight every time a person is choking during sleep.
The most common symptom of sleep apnea is chronic snoring. "Culturally, snoring has been thought of as a funny thing," says Dr. Knapik, "but it can indicate a serious problem."
For Dr. Al-Ajam, it was during his work at a sleep lab in Arkansas that upped his involvement in sleep medicine and the importance of sleep labs. One of the nurses he worked with was married to a Veteran, "She complained that he snored horribly at night and that she heard him choking," says Dr. Al-Ajam, "I told her he probably had sleep apnea and to get him to the lab."
But he refused the study, and shortly after, Dr. Al-Ajam got a phone call saying that this nurse's husband just had a heart attack, "I was like, What are you talking about? He was in his mid 30’s, what kind of heart attack could be he having?" After the heart attack, he came in for the sleep study. "This was the worst sleep apnea case I had ever seen. He was choking three times a minute while he slept."
Dr. Al-Ajam encouraged his sleep lab to take on more patients and eventually they got certification, "I said, you know, were going to make this into a project." A few years later he is now at this brand new Brooklyn Sleep Center, and the goal is to diagnose these veterans before it causes permanent damage.
"Snoring is not something to ignore. This thing is really important," he says, "Many of these guys come back from combat and drive or operate heavy machinery. They want to hold jobs and sustain themselves and their families, so we help them that way."