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    • If your Apple Watch alerts you to sleep apnea, here's what it means and what to do next

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    Already multitool smart devices, Apple Watches added another buzzworthy feature last month: an app to detect .

    Sleep apnea is that causes a sleeper鈥檚 breathing to pause when the muscles of the throat relax too much and the airway collapses. It can contribute to loud snoring, which the sleeper may not even be aware of. Typically, a partner or roommate picks up on the problem first.

    The condition has been linked to a host of health problems, primarily wear and tear on the cardiovascular system, including high blood pressure, stroke, heart attack, heart failure and heart rhythm problems such as atrial fibrillation. It鈥檚 also been tied to dementia and daytime sleepiness. And people with sleep apnea are more likely to be involved in traffic accidents, too.

    Millions of people to have this disrupted breathing condition but have not been diagnosed, and experts say the new app could be a valuable tool to point people to medical care. The sleep apnea notification is available on the latest Series 10 Apple Watches and some older models after a software update.

    As with any kind of new technology, however, the sleep apnea feature has limitations and can have unintended consequences, including worse sleep if someone becomes too focused on the information or anxious about the results.

    鈥淲e are seeing this phenomenon called orthosomnia. It鈥檚 people that get overly anxious about their sleep data and how they maximize and improve their sleep. And they go sometimes to extremes,鈥 said Dr. Robson Capasso, the chief of sleep surgery at the Stanford University School of Medicine.

    They may turn to risky supplements or extreme diets in pursuit of an ideal night鈥檚 rest.

    New ways to track sleep don鈥檛 have to be source of stress, though.

    鈥淚 feel that this is a great tool. It just needs to be implemented correctly,鈥 Capasso said.

    Erring on the side of caution

    The Apple Watch鈥檚 new feature uses the device鈥檚 accelerometer, which measures movement, and Apple says it鈥檚 so sensitive it can detect even very slight movements of the wrist that correspond with breathing at night.

    However, it鈥檚 an opt-in feature, so it must be turned on to start working.

    In order to detect sleep apnea, the watch measures breathing disturbances during sleep over 30 days. If there are at least 10 sessions with breathing pauses, and at least five of these have abnormally high numbers of pauses, the watch sends a notification to the user.

    How well does the feature work?

    Apple in almost 1,500 people, some who had normal breathing during sleep and others who had varying degrees of sleep apnea. Each wore the watch for at least 30 nights and also did at least two nights of a more conventional home sleep study with a monitor that recorded a host of factors including nasal pressure, blood oxygen, body position, breathing effort, pulse and leg movement.

    Researchers used this home sleep study data to determine each person鈥檚 apnea-hypopnea index, the number of times per hour that breathing stops or is reduced. Researchers then compared how well the watch performed to the measures taken during the sleep study.

    In general, Apple鈥檚 testing found that the watch picked up on any degree of sleep apnea about 66 per cent of the time. It was more accurate at detecting severe bad sleep apnea, correctly alerting users about 89 per cent of the time. It correctly alerted users to moderate breathing problems about 43 per cent of the time.

    Apple said it tweaked the watch鈥檚 algorithm to err on the side of not giving false positives that might scare users, and that seems to have worked. The new alert didn鈥檛 tell normal sleepers that they had sleep apnea 100 per cent of the time.

    So, if you get an alert, you can be fairly confident that the result is real and needs follow up with your primary care doctor or a sleep specialist. On the other hand, if you don鈥檛 get an alert, it doesn鈥檛 necessarily put you in the clear. You may still have sleep apnea, especially if you have other suggestive symptoms.

    The company鈥檚 study hasn鈥檛 been peer-reviewed by outside experts or published in a medical journal. But the US Food and Drug Administration of the sleep apnea feature on Apple Watches in mid-September.

    There are other wearable devices that also promise to help people figure out whether they have sleep apnea, but the fact that this is an Apple entry into the market has gotten some attention.

    鈥淚t has come up so many times in conversation,鈥 said Dr. Jing Wang, clinical director of the Mount Sinai Integrative Sleep Center. 鈥淚 have become more aware of it.鈥

    The algorithm vs. a sleep doctor

    Wang says the way the watch works is different from the steps she goes through to make a diagnosis. The watch is relying on wrist movements, but she starts with symptoms.

    鈥淥ther than the watch saying this, or other than your tracker saying this, what else have you experienced?鈥 Wang said.

    Notably, the watch doesn鈥檛 ask about symptoms. It also doesn鈥檛 use the pulse oxygen feature, which has disappeared on some Apple watches because of .

    Wang says typical things that tip her off to sleep apnea include loud snoring 鈥 although not everyone who snores has apnea 鈥 a partner who says they can鈥檛 sleep because of the noise or who has heard their bedmate stop sleeping at night, a patient who reports waking up choking or gasping, and someone who says they wake up tired or feel exhausted during the day. Morning headaches, high blood pressure and memory problems can also be in the mix, she says.

    After this conversation, she would order a sleep study if she thinks it鈥檚 necessary. These can be done at home or in a sleep lab, which typically requires an overnight stay at a hospital or sleep center. Sleep studies record multiple variables including blood oxygen, respiratory rate, pauses in breathing and nighttime awakenings.

    The Apple Watch has a few of these capabilities, but the company did not factor them into the sleep apnea feature. If it had, it might have been better able to detect mild and moderate cases of apnea, says Dr. Eric Topol, a cardiologist who is founder and director of the Scripps Translational Research Institute.

    鈥淲hen their watch had pulse oximetry in it 鈥 now lost 鈥 it would have provided useful data, at least in people not of colour,鈥 Topol wrote in an email. Studies have shown that wearable devices to detect oxygen, called pulse oximeters, are not as accurate in people with darker skin tones, for better devices that are tested on more diverse populations.

    鈥淯nlike home tests or sleep labs, where oxygen saturation is continuously measured, the Apple watch algorithm relies on accelerometer measurements of movement, which would explain low sensitivity.鈥

    It may not be such a bad thing that the watch is not so sensitive, Stanford鈥檚 Capasso said.

    Even with full sleep studies, answers are not clear-cut. The main measure of a sleep study 鈥 the apnea-hypopnea index, or AHI 鈥 doesn鈥檛 always correlate with symptoms, he said. And not all cases of sleep apnea need to be treated.

    How sleep apnea is treated

    Capasso says that if a patient has many episodes of interrupted breathing and a bunch of drops in oxygen, he knows they need to be treated with a continuous positive airway pressure machine, or CPAP.

    The machine is a 鈥済lorified air compressor鈥 that delivers a steady stream of air through a mask to hold the airway open during sleep.

    鈥淭here is plenty of evidence that these patients with frequent drops in oxygen, they have a closer correlation with clinical outcomes down the road, in particular cardiovascular outcomes,鈥 he said.

    If he has a patient with an AHI that puts them in the mild to moderate category and they鈥檙e also having daytime symptoms of sleepiness and brain fog, he might also try CPAP.

    Not everyone has success with these machines, though. Half of patients who are prescribed this therapy don鈥檛 use it the way they should, Capasso said.

    For some people with mild apnea, the key to better rest may lie with other options, such as weight loss 鈥 which often cures the problem in people who are overweight or obese 鈥 and fixing poor sleep hygiene.

    鈥淎 lot of time, fixing bed-related habits is enough,鈥 he said.

    In younger adults with sleep apnea who are not overweight, he might look at anatomical features, like the size of their jaws and tonsils, which can be a factor too.

    In the end, he says, he considers a person鈥檚 age and the severity of their condition when deciding how aggressive to be with treatment.

    Capasso thinks the Apple Watch alerts will be helpful for people who live alone or who don鈥檛 have easy access to sleep studies and specialists.

    鈥淭his can be quite a good screening tool,鈥 he said.

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