Wednesday, January 4, 2017

Multiple Sclerosis and Sleep Apnea

In 2009, I was diagnosed with Multiple Sclerosis... 

My life has never been the same. As a mother of six, a business owner and a loving wife; this disease has had a tremendous effect on my life.

"Multiple sclerosis is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body." (1) Multiple sclerosis is not very well understood and scientist still do not know what causes MS. 

Patients with MS suffer from a deterioration (demyelination) of the myelin sheath, which surrounds the nerve fibers throughout their nervous system. It is believed to be caused by environmental factors that are not yet known, which affect a person who is predisposed. One thing that is known about multiple sclerosis, is that three times more women get this disease than men. 

When people think of sleep apnea, they generally think of more common comorbidities (diabetes, obesity, heart failure, hypertension, etc). BUT THE VAST MAJORITY OF PEOPLE ARE UNAWARE OF THE RELATIONSHIP BETWEEN SLEEP APNEA & MULTIPLE SCLEROSIS.

A new study performed by the American Academy of sleep medicine indicates that around 1/5 of a patient suffering from multiple sclerosis will also suffer from obstructive sleep apnea. The study also indicates that almost half the patients who suffer from multiple sclerosis are at an elevated risk of suffering obstructive sleep apnea.

Understanding this relationship is very important and could change the way multiple sclerosis is viewed. This is because one of the most common symptoms of multiple sclerosis is debilitating fatigue. Patients, like myself, who suffer from multiple sclerosis will often find themselves exhausted for days on end, regardless of how much sleep we get it.

BUT it is important to understand that fatigue is also a very common symptom of obstructive sleep apnea. Since obstructive sleep apnea greatly reduces the amount of REM sleep a patient is able to get during the night, patients who suffer from sleep apnea will also suffer from debilitating fatigue.

THAT IS WHY it is important that patients suffering from multiple sclerosis, inquire with their physicians who are involved in their treatment about the possibility of them also suffering from obstructive sleep apnea. By tackling the possibly correlated obstructive sleep apnea, one could greatly reduce the debilitating effects of multiple sclerosis

-Miss Sleep


(1). National multiple sclerosis society. "What is MS?"

(2). Sleep "The link between Sleep Apnea and MS." post/88621749594/the-link-between-sleep-apnea-and-ms-by-gina

Answers To Frequetly Asked Questions By Physicians about HOME SLEEP TESTING

How will Home Sleep Testing help my practice?

Home Sleep Testing has been around for many many years and is now being utilized by many in as the primary tool for diagnosing Sleep Apnea. This is partly because Home Sleep Studies are shown to be around 1/2 to 1/4 the cost of the cumbersome In-Lab Overnight Sleep Study. Many insurance companies now require a HST as a first line diagnostic tool. "With proper screening, up to 75% of patients suspected of having moderate to severe Sleep Apnea will only need to have a HST performed to get their diagnosis, making an in-lab study unnecessarily expensive. (1)

In spite of this, it surprising how many doctors still do their best to refer patients to overnight sleep facilities in almost every case they see. I thought that it would be beneficial for everyone to provide some answers to some of the common questions that physicians ask about Home Sleep Testing...... 

Enjoy :)

Answers to Physicians' FAQs about Home Sleep

Healthier patients, better acceptance: Home Sleep Testing (HST) is typically preferred by patients over in-lab studies. They appreciate being able to sleep in their own bed with no one watching them. Patients also appreciate the convenience of an HST. There are no long drives to a sleep lab, and no waiting for an opening to make an appointment. Cost is also a very big concern for patients, particularly those with high co-pays and deductibles. The full cost of an IDS HST is typically less than the co-pay of a lab visit. See the patient section of this website for more benefits to patients. 
More revenue and better relationships per patient: Medicare requires at least two office visits for all Obstructive Sleep Apnea (OSA) patients now: one prior to testing (HST or PSG in a lab) to confirm the patient is a candidate; and a second follow-up between the 31st and 91st day of PAP treatment to determine if the patient is showing clinical improvement. In a sleep lab situation, these visits are typically handled by the sleep physician; while primary care physicians (PCP) prefer to keep their patients in their office. Therefore, IDS provides the PCP with easy-to-read test reports and simpler treatment and titration when utilizing today's auto-titrating PAP equipment with their built-in compliance and efficacy reporting. There may even be additional CPAP initiation codes that can be billed depending on the situation (speak with your CPAP supplier for more information) and insurer. These extra office visits are great opportunities for the PCP to learn more about their patient and strengthen their doctor-patient relationship.
Test results interpreted by a board certified sleep physician: Our panel of board certified sleep physicians reviews and interprets each study and makes treatment recommendations.
Faster results: Many hospital-based and independent sleep labs require a consult with the sleep physician prior to testing. They also have a limited number of beds, making appointment scheduling a long, drawn-out process. IDS not only allows PCPs to refer directly, but provides results in as few as 5 days, and typically less than 10, from the date the PCP orders the test. Patients will likely be treated, on therapy, and getting relief in a week, rather than months later as in many sleep lab programs.
Less hassle: The IDS HST referral form and process is extremely simple. IDS handles insurance verification when needed, allowing the PCP's staff to save time by not having to get approval for a specialist referral.
How reliable is HST technology?
HST technology has been around for more than two decades. It has effectively lowered healthcare costs in Australia, Europe and Canada. Within the past five years, improvements to the technology have made it even more reliable. HST devices now include faster sampling rates on the oximetry channels (better correlation between channels) and simpler setup procedures for patient self-application.
It's difficult to do direct comparisons between the sleep lab and the home because of individual differences from night to night. However, HST is probably slightly less reliable for patients with a borderline Apnea Hypopnea Index (AHI) because sleep time is not measured. That is why Medicare and other insurers have said that it cannot be used as a screener; HST should only be used to confirm sleep apnea in patients with clinical symptoms.
For peer-reviewed articles supporting HST and the historical perspective, refer to the section titled Clinical Evidence. 
Who is a candidate for HST?
HST is intended for patients who exhibit clinical symptoms of Obstructive Sleep Apnea (OSA). Patients with other sleep disorders (i.e. Restless Leg Syndrome (RLS), narcolepsy, REM-behavior disorder), co-morbid conditions (which may impact the diagnostic relevance of the SaO2 data such as COPD or CHF), and patients in whom you only mildly suspect sleep apnea ARE NOT candidates for HST. Patients with hypertension or diabetes ARE candidates, as are those that exhibit symptoms of insomnia. In fact, middle-aged women with OSA may present as sleep maintenance insomniacstheir OSA could be made worse with hypnotics (Reference: Shepertycky et al.). Signs to watch for include:
  • Loud snoring
  • Witnessed apnea events
  • Excessive daytime sleepiness
  • Morning headaches
  • History of high blood pressure
  • Memory problems or poor judgment
  • Depression
  • Gastroesophageal reflux
  • Impotence
  • Nocturia
  • Difficulty concentrating
  • Personality changes or irritability
How do I perform the clinical assessment?
First, you will uncover patients at risk for OSA in one of two ways. They are:
  • Ask the patient to complete the Epworth Sleepiness Scale.
  • Ask the patient the Five Simple Questions for OSA Screening which include:
    • Do you snore?
    • Are you excessively tired during the day?
    • Have you been told you stop breathing during sleep?
    • Do you have hypertension?
    • Is your neck size greater than 17 inches (male) or 16 inches (female)?
If your patient answers "yes" to at least two questions he is a candidate for HST.
Finally, do a cardiopulmonary assessment to rule out exclusionary disorders such as COPD and CHF. Examine the upper respiratory airway looking for enlarged tonsils, obvious asymmetries or blockage of the nasal passages and document your findings in the patient’s chart.
How fast can I get the report?
IDS typically contacts the patient and ships a device the same day the order is received. We process the data and provide an interpretation within a matter of hours of it being returned by the patient. Typical turnaround time is 7-10 days from the physician's order to test results.
What is the cost to the patient?
That depends on the patient's insurance. For example, the cost for a patient with Medicare and no supplemental insurance is $30.25 (depending on Medicare allowable). The cost will never be more than $250, even for those without insurance. To put it in perspective, an HST is between one-fifth to one-tenth the cost of an in-lab sleep study.
What data will I get?
IDS uses the ResMed ApneaLink Plus Type III device which records four channels from two sensors. A nasal pressure cannula records airflow and snoring, while a finger sensor records oxygen saturation and heart rate. The Type III ApnaeaLink device also records respiratory effort. See the section titled Sample Test Report for more specific examples.
Will my older patients be able to follow instructions? 
IDS provides an instructional DVD that illustrates how to apply the device and very detailed printed instructions which have been developed based on our success in home overnight oximetry testing. The instructional brochure contains professionally drawn illustrations developed just for IDS patients who may have trouble reading the instructions. The illustrations include diagrams showing them applying the nasal cannula, sliding on the finger sensor, confirming the device is working and packing equipment back in the envelope. We also provide a toll-free, support line that is available 24/7. IDS Patient Support is staffed by qualified sleep technicians for patients who still have questions or experience difficulties. Our success rate of 98% easily exceeds published industry standards.
Can I do follow-up studies? 
Medicare, and possibly other insurers, will only allow the new HST code to be billed once per year. However, an overnight oximetry test can be performed to determine whether or not a patient still has oxygen desaturations while on CPAP.
A DME in my area is doing the testing themselves. Can they do that?
For Aetna, Humana and private pay patients, they can. However, Medicare excludes a company or its affiliate from diagnosing and treating a patient. Unlike oximetry testing in which the DME can deliver the device and act as a "courier of equipment". The DME is not to be involved in HST in any way according to CMS rules.
IDS is the only company that, as an independent diagnostic testing facility (IDTF) without any co-ownership ventures with DMEs, can test patients with any insurance, in any state without risk of penalties.
Another company is including the clinical evaluation as part of their HST service. Isn't that a better option?
Medicare has made it clear that both the evaluation and the follow-up visits must be done by the treating physician (there are allowances for nurse practitioners under the treating physicians to be involved). These services are fine for private pay patients or insurers whose policies differ from Medicare's, but it's difficult to track of which policies approve and which policies disapprove.
The intent of IDS Sleep is to help PCPs become more comfortable talking with their patients about their sleeping habits. Treating sleep apnea has been shown to improve glucose control in diabetics, lower blood pressure, reduce the risk of heart disease and stroke and increase energy, allowing patients to exercise and lose weight. With discussions at the nation's capital focusing on pay-for-performance and the medical-centered home, we believe this approach benefits patients and makes PCPs more likely to succeed should such changes be implemented.
What's going to happen to the sleep labs? My hospital just spent a lot of money to build one.
HST is for uncovering sleep apnea specifically. We anticipate that as physicians begin asking questions about sleep, other issues which require a comprehensive evaluation in a sleep lab will be uncovered.
Where can I find guidelines for administering Auto-Titrating Positive Airway Pressure (APAP) treatment following a positive test and clinical evaluation?

The AASM (American Academy of Sleep Medicine) provides practice parameters on their website.(2)

-Miss Sleep
(1). (Sep, 2013). K. Philips. Home Sleep Tests V.S. In Lab Tests; Which is Best? Alaska Sleep Education Center. Retrieved from:
(2) (June, 2008). Instant Diagnostic Systems. "Frequetly Asked Questions By Physicians" Retrieved from: content.aspx?content=Physician_Home_Sleep_Testing_FAQ