Assistance With Sleep Apnea Claim

[bolt_vet23]

Hello,

I'm hoping someone can help me out. I separated from the Air Force in 2005 and the Veteran's representative recommended that I claim sleep apnea so I did, but was not found to have it based on the take home stardust test. I know that I did not take the test correctly, but didn't think anything of it...just a snoring problem. I filed a claim eight years later and took another take home test which proved to be inconclusive. However, the doctor discussed the test results and symptoms and recommended that I take the overnight test. The results showed that I have sleep apnea so I submitted the results along with buddy letters and detailed letter from my wife, but was still denied. The letter states that sleep apnea was not caused by aggravated military service. It also says that there was no evidence to support that the disability was present during military service. There is no evidence from when I served because I just thought that it was a snoring problem...I was in my early 20s and had no idea what sleep apnea was at this time.

At this point, what options do I have? I know for a fact that the sleep apnea became apparent while deployed during OIF/OEF, but like I said, I never went to the doctor because I didn't know what it was at that time. Is there any want to link it to military service?

Appreciate any assistance.

[camidonHP]

IF you already have a service-connected mental disorder, you might be able to get OSA connected:

Here's the research I have on the relationship(s) between Obstructive Sleep Apnea and mental disorders:

Correlation/Comorbidity between OSA and PTSD

Sharafkhaneh et al (2005) Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort SLEEP, Vol. 28, No. 11

"Our data show that the prevalence for comorbid psychiatric conditions is significantly higher in individuals with diagnosed sleep apnea than in individuals not diagnosed with sleep apnea.

This pattern was most pronounced for mood disorders (depression and bipolar disorder), PTSD, and other anxiety disorders."

“Our data strongly support an association between sleep apnea and PTSD.”

11.85% of the PTSD group has OSA, compared with 4.74% of the non-PTSD group. Odds ratio=2.70

(Note: Also supports depression/anxiety as secondary to sleep apnea.)

Krakow et al (2001) Complex Insomnia: Insomnia and Sleep-Disordered Breathing in a Consecutive Series of Crime Victims with Nightmares and PTSD BIOLOGICAL PSYCHIATRY 949 49:948–953

Study of crime victims with PTSD. “Sleep-disordered breathing was diagnosed in 40 of 44 patients; 22 patients met OSA criteria.”

Sharafkhaneh et al (2005) Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort SLEEP, Vol. 28, No. 11,

Compared the prevalence of sleep-apnea diagnoses in subjects with and without specific psychiatric diagnoses. 11.85% of the PTSD group has PTSD, compared with 4.74% of the non-PTSD group. Odds ratio=2.70

PTSD Causes sleep disturbances

Orr (2011) Sleep Disturbances and Posttraumatic Stress Disorder Medscape Pulmonary Medicine

This isn’t peer-reviewed, just a web article, but is a good review of research that shows sleep disturbances are related to PTSD. The only time it mentions apnea is when it references Krakow (2011)

Krakow et al (2002) To Breathe, Perchance to Sleep: SleepDisordered Breathing and Chronic Insomnia Among Trauma Survivors Sleep and Breathing/volume 6, number 4

Good review of research that shows higher rate of sleep disordered breathing and fragmentation.

Sleep Deprivation Causing or Worsening Apnea

Series F, Roy N, Marc I.(1994) Effects of sleep deprivation and sleep fragmentation on upper airway collapsibility in normal subjects. Am J Respir Crit Care Med 150:481–5

Sleep fragmentation (such as is prevalent in PTSD [see: van Liempt, 2011]) increases the propensity for upper airway collapse in patients with sleep apnea.

Krakow, 2001 Complex Insomnia: Insomnia and Sleep-Disordered Breathing in a Consecutive Series of Crime Victims with Nightmares and PTSD

Guilleminault C, Rosekind M. (1981) The arousal threshold: sleep deprivation, sleep fragmentation, and obstructive sleep apnea syndrome. Bull Eur Physiopathol Respir. 1981;17(3):341-9.

Shows that sleep deprived patients have increased frequency and length of apneic events, similar to the effects of alcohol.

(Also useful for nexus, as it talks about how prolonged shift work (such as military watches) can cause the sleep deprivation that worsens apnea. )

Leiter JC, Knuth SL, Bartlett D Jr (1985) “The effect of sleep deprivation on activity of the genioglossus muscle)” The American Review of Respiratory Disease [132(6):1242-1245]

Sleep deprivation appears to increase the severity of obstructive sleep apnea, due to decreases in genigoglossus activity.

Eckert et al (2011) Sleep Deprivation Impairs Genioglossus Muscle Responsiveness Am J Respir Crit Care Med 183;2011:A6163

These data indicate that acute sleep deprivation leads to potentially important reductions in genioglossus muscle activity. In particular, muscle responsiveness to chemical (hypercapnia), and mechanical (resistive loads) stimuli is impaired by approximately 60% following acute sleep deprivation. These data suggest that sleep deprivation may initiate or worsen OSA, at least in part, via impaired upper airway dilator muscle function.

Persson, Svanborg (1996) Sleep Deprivation Worsens Obstructive Sleep Apnea Chest. 1996;109(3):645-650

Showed an increase apneic events and longer apneic events after sleep loss.

PTSD decreases Slow Wave Sleep, which worsens apnea

McSharry et al (2012) A Mechanism for Upper Airway Stability during Slow Wave Sleep SLEEP, Vol. 36, No. 4, 2013

This shows that the severity of apnea is diminished during slow wave sleep. The next study shows that slow wave sleep is greatly diminished in PTSD.

Fuller, K. H., Waters, W. F., & Scott, O. (1994). An investigation of slow-wave sleep processes in chronic PTSD patients. Journal of anxiety disorders, 8(3), 227-236.

“Overall, PTSD subjects had a decreased percentage of slow-wave sleep relative to controls, which may explain their increased arousals during the first half of the night.”

Stress from PTSD symptoms worsen OSA

Nakata et al (2007) Perceived job stress and sleep-related breathing disturbance in Japanese male workers Social Science & Medicine 64 (2007) 2520–2532

Shows that sleep-disordered breathing increases with proportion to occupational stress, as well as anxiety and depressive symptoms. (Kind of a weak paper, scientifically, though.)

Sleep Deprivation/Fragmentation occurs with PTSD

van Liempt et al (2011) Decreased nocturnal growth hormone secretion and sleep fragmentation in combat-related posttraumatic stress disorder; potential predictors of impaired memory consolidation Psychoneuroendocrinology (2011) 36, 1361—1369

Sleep was more fragmented in patients with PTSD, with more awakenings in the first half of the night. (Also shows that these awakenings lead to lower GH production, which may explain the memory problems in PTSD patients)

Psychiatric Times Sleep Disturbances Associated With Posttraumatic Stress Disorder

Insomnia and other sleep disturbances occur frequently in patients with PTSD and they can be severe.

Sleep problems worsen PTSD

Belleville, Guay, Marchand (2009) “Impact of Sleep Disturbances on PTSD Symptoms and Perceived Health” The Journal of Nervous and Mental Disease Volume 197, Number 2, February 2009

The present study highlights the important role sleep plays in PTSD. Sleep appears to have a unique contribution in accounting for the severity of PTSD symptoms. Sleep also impacts how individuals with PTSD perceive their own mental health. Most individuals with PTSD present significant sleep difficulties regardless of their clinical presentation.

Spoormaker (2008) Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature? Sleep Med Rev. 2008 Jun;12(3):169-84.

This article is about how PTSD may be worsened or aggravated by sleeping issues, and suggests sleep disturbances may be risk factors for PTSD.

Benzos/Meds worsen apnea

Dolly FR, Block AJ. Effect of flurazepam on sleep-disordered breathing and nocturnal oxygen desaturation in asymptomatic subjects. Am J Med. 1982;73:239–43.

Hanly P, Powles P. Hypnotics should never be used in patients with sleep apnea. J Psychosom Res. 1993;37:59–65

Berry RB, Kouchi K, Bower J, Prosise G, Light RW. Triazolam in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 1995;151:450–4.

Hope this helps!

Edited July 21, 2015 by camidonHP

[ArNG11]

Excellent sources

[Andyman73]

I am hoping that there is enough evidence in my own SMR covering stress related ailments. As I had/have chronic gastro-intestinal and sinus issues, documented in my SMR, and sleepleness also. And alcohol abuse as well. I am currently DX by private dr with SA, use CPAP also.

[bolt_vet23]

I went back through my VA documents and noticed that in the original rating from 2005 it states "You advised the examiner that you wished to drop the claim for sleep apnea based on these facts." The facts that they reference are that I told them that I took a take-home/stardust sleep apnea test prior to separating and that the results came back negative. However, the rating also states "The examiner states a diagnosis of heroic snoring, and notes there was no functional impairment found on your examination."I don't recall ever seeing the results but I do know that I didn't take the test correctly. I went back through all of my medical records but I'm unable to locate the test results. I've requested a copy of my medical records again just in case they forget to include them when I separated. In 2006 the VA received my full military records and stated that after they reviewed them that their previous decision stands.

Hopefully I can get the doc to write a nexus letter, but I'm a bit concerned since I don't have anything documented in my medical records. Frustrated!

[bolt_vet23]

All,

I'm meeting with a private doc tomorrow for an independent assessment and want to be prepared with an example nexus letter. Do you think that this will suffice? I have SC for allergic rhinitis and am hoping that it's the missing link since there's no sleep problems documented in my military records. I appreciate everyones assistance.

PROPOSED NEXUS

Doctor's Letter Head

Date:

Subject: Independent Sleep Apnea Analysis for Mr. XXXX

Reference: C-File # and/or Social Security Number

To the Department of Veterans Affairs:

I am a neurologist who performed an independent assessment of Mr. Veteran’s medical records. I practice neurology and am board certified by XXXX.

I personally reviewed Mr. Veteran’s medical history including his service medical records dated X to X, initial rating decision from the VA, VA medical records dated X and sleep study results dates X and X. It is my opinion that it is more likely than not that Mr. Veteran displayed symptoms of sleep apnea due to his service connected allergic rhinitis. The continuous nasal congestion that is documented throughout Mr. Veteran’s service medical records and VA medical records only exacerbate the problem.

Respectfully,

Dr. XXXX
Diplomat of the American Board of Internal Medicine

[Andyman73]

Hopefully that will be enough to get them to see the light.