A person can spend eight or nine hours in bed and still wake up exhausted.
For people with sleep apnea, the problem is not necessarily how long they sleep but what happens while they are sleeping. Their breathing repeatedly slows or stops, oxygen levels may fall and the brain briefly pulls them out of deeper sleep so breathing can resume.
Sleep apnea is common, serious and frequently undiagnosed. Left untreated, it can increase the risk of high blood pressure, heart disease, stroke, diabetes and problems with mood, memory and concentration. But improved testing and treatments are making it easier to manage.
Many people may not remember the repeated awakenings, says Dr. Jennifer So, medical director of the Sleep Laboratory at the University of Maryland Medical Center Midtown Campus and an assistant professor of medicine at the University of Maryland School of Medicine.
More than snoring
Sleep apnea often goes unnoticed because its most serious disruptions happen after a person falls asleep.
“In obstructive sleep apnea, the body is trying to breathe, but a narrowed or collapsed airway blocks the air from reaching the lungs,” So says.
That can lower oxygen levels and cause an awakening. The person may not remember waking, but repeated interruptions can prevent restorative sleep.
Central sleep apnea has a different cause. Instead of a blocked airway, the brain temporarily fails to send signals that trigger breathing. So says certain medications and neurological or metabolic conditions can interfere with those signals.
Snoring is closely associated with the disorder, but it is not the only symptom. A bed partner may notice pauses in breathing followed by choking or gasping. People may also wake with headaches or a dry mouth, have trouble concentrating, experience mood changes or become sleepy during the day.
“Not everyone with obstructive sleep apnea snores,” So says. “Not everyone with OSA is obese.”
Excess weight is an important risk factor because tissue around the neck can narrow the airway. But anatomy matters as well. Enlarged tonsils, a crowded throat, a smaller jaw or a chin positioned farther back may leave less room for air to pass.
“Sleep apnea is not limited to people with obesity,” So says. “In fact, it may be overlooked in patients who are not overweight.”
Family history can increase risk. Alcohol near bedtime may relax airway muscles and worsen obstructive events. So says opioids, benzodiazepines and other sedating medications can reduce upper-airway muscle tone or interfere with breathing.
Women’s risk rises after menopause as hormonal changes affect airway stability and fat distribution.
“Menopause changes the equation,” So says. “A woman’s risk of sleep apnea rises sharply and becomes nearly equal to a man’s.”
Untreated sleep apnea does more than leave people tired. Research has linked it to high blood pressure, heart disease, stroke, atrial fibrillation and problems controlling blood sugar, So says.
Repeated drops in oxygen and surges of stress hormones strain the cardiovascular system. Patients with sleep apnea may have especially stubborn hypertension, So says.
Poor-quality sleep can affect nearly every part of the following day. It may slow reaction time, make it harder to focus or remember information and interfere with work, decision-making and emotional control. Severe daytime sleepiness can also make driving unsafe.
“Each breathing interruption can partially or fully awaken the sleeper, causing disruptions in overall sleep quality.”
Home tests and sleep labs
Diagnosis requires a sleep study.
Home testing can be appropriate for otherwise healthy adults with a high likelihood of moderate to severe obstructive sleep apnea. The patient wears a portable monitor at home and returns it for interpretation.
“It should only be used for generally healthy patients who are at high risk of having moderate to severe OSA,” So says.
The test may miss mild disease or other sleep disorders.
An overnight study in a sleep laboratory, called polysomnography, is more comprehensive. It can record airflow, oxygen levels, brain waves, heart rhythm, muscle activity and sleep stages. It may be recommended when central sleep apnea, unusual nighttime behaviors or movement disorders are suspected.
“It is still the gold standard,” So says.
Treatment beyond CPAP
Continuous positive airway pressure, commonly called CPAP, remains the standard treatment for obstructive sleep apnea. A bedside machine delivers pressurized air through a mask, helping keep the airway open.
Some people struggle with the mask, air pressure, dryness or leaks. So says many problems can be corrected by changing the mask, adjusting the settings, adding humidification or consulting a sleep specialist.
“The main barrier is often having another device that the patient has to remember to put on at nighttime,” she says.
CPAP is not the only option. Custom-fitted oral appliances move the lower jaw and tongue forward to create more space in the airway. They may help patients who cannot tolerate CPAP.
Selected patients may qualify for an implanted nerve stimulator, which helps keep the tongue from blocking the airway. So described it as similar to a pacemaker that stimulates a nerve and moves the tongue forward.
Medication has also entered the treatment picture. In December 2024, the Food and Drug Administration approved Zepbound, or tirzepatide, for moderate to severe obstructive sleep apnea in adults with obesity when used with diet and exercise.
Lifestyle changes remain important, including exercise, limiting alcohol before bed and maintaining consistent sleep habits. But weight loss alone may not eliminate apnea when jaw structure or airway anatomy is driving the condition.
“Obstructive Sleep Apnea is not driven purely by weight,” So says.
The expanding treatment choices reflect a broader shift in sleep medicine. Doctors increasingly recognize that not every patient has the same form of obstructive sleep apnea or will respond to the same therapy, So says.
Anyone concerned about snoring, choking during sleep, persistent fatigue or daytime sleepiness can start by speaking with a primary care doctor. A sleep-medicine physician can provide a detailed evaluation.
“Diagnosis and treatment can really have a big positive impact on quality of life as well as overall health,” she says.
