Sleep apnoea - how to tell if you have it

Obstructive sleep apnoea is the most underdiagnosed condition in middle-aged adults. Estimates put the UK prevalence of moderate-to-severe disease at 4 to 5 percent of men aged 40 to 70 and 2 percent of women, with probably twice that again undiagnosed. Most patients do not suspect it because the classic stereotype (loud snoring, witnessed choking) does not describe most actual cases. This article lists the real symptoms and the specific questions that matter.

What apnoea actually is

Obstructive sleep apnoea is repeated partial or complete collapse of the upper airway during sleep. Each event causes an oxygen desaturation, a sympathetic nervous system spike, and a brief arousal that fragments sleep. The patient is usually unaware of the events.

The Apnoea-Hypopnoea Index (AHI) counts events per hour. Mild apnoea is 5 to 15, moderate is 15 to 30, severe is over 30. Above 30 events per hour means one event every two minutes across an entire night, which produces the full-blown clinical picture.

Central sleep apnoea, a separate condition, is much rarer and has different causes (heart failure, opioid use, certain brain conditions). The focus of this article is obstructive.

Who gets it

Men more than women before menopause, then the ratio narrows. Post-menopausal women have rates approaching those of men.

Higher BMI is a strong risk factor. Neck circumference over 17 inches in men or 16 inches in women is predictive.

Structural airway features: small lower jaw, narrow upper airway, enlarged tonsils, large tongue, crowded oropharynx, nasal obstruction.

Smoking, alcohol, sedative use, and testosterone supplementation all increase upper airway collapsibility.

Genetic predisposition exists. Apnoea runs in families at rates greater than chance.

The symptoms most people actually report

Waking unrefreshed despite spending adequate time in bed. The classic signature. Eight hours of heavily fragmented sleep is not restful. Morning grogginess lasting an hour or more. Consistent need for mid-morning caffeine just to function.

Unexplained daytime sleepiness. Nodding off in meetings, in front of the TV, or on the train. The Epworth Sleepiness Scale is a validated screen; scores of 10 or more warrant investigation.

Morning headaches. Specifically, dull frontal headaches on waking that ease through the morning. Caused by overnight hypercapnia. Not every morning headache is apnoea, but unexplained recurrent ones should trigger a sleep-study question.

Brain fog and poor concentration. Often attributed to age or to "just being busy". In significant apnoea, the cognitive effect is marked and reversible with treatment.

Low mood, irritability, reduced motivation. Fragmented sleep makes mood regulation harder. Many men diagnosed with low-grade depression have underlying apnoea driving part of the picture.

Nocturia (waking to urinate multiple times a night). Apnoea-induced overnight atrial natriuretic peptide secretion is a real mechanism. Men who wake three or four times overnight thinking it is their prostate often have apnoea.

Partner's observation. If your partner has seen you stop breathing, that is meaningful. If they kick you to roll over to make you breathe, that is meaningful. If they sleep in another room because of snoring, that is meaningful. Partners often know you have apnoea before you do.

Reflux, gastric symptoms at night. Apnoea predisposes to overnight reflux through negative intrathoracic pressure during obstructive events.

Cardiovascular red flags. Treatment-resistant hypertension (needing three or more medications to control), atrial fibrillation in younger patients, unexplained heart failure, new-onset stroke. Any of these should trigger apnoea investigation if it has not already been done.

The symptoms that do NOT reliably indicate apnoea

Snoring alone, without daytime symptoms or witnessed apnoea, is usually benign. Many people snore without significant apnoea. Snoring plus apnoea symptoms (unrefreshed waking, sleepiness) is a different picture.

Insomnia alone (difficulty falling asleep, difficulty staying asleep) is usually not apnoea, though the two can coexist (COMISA).

Early morning waking without other features is more likely depression, substance use, or anxiety than apnoea.

Validated screening tools

STOP-BANG questionnaire. Eight yes/no questions: Snoring, Tiredness, Observed apnoea, high blood Pressure, BMI over 35, Age over 50, Neck over 40cm, Gender male. A score of 5 or more indicates high probability of moderate-to-severe apnoea.

Epworth Sleepiness Scale. Eight items rating likelihood of dozing off in different situations. Total above 10 is excessive sleepiness.

Berlin questionnaire. Three-category screening tool covering snoring severity, daytime sleepiness, and hypertension/obesity risk.

Any single screen is imperfect. Combining STOP-BANG and ESS catches most significant apnoea.

Who definitely needs testing

Men or women with three or more of the STOP-BANG criteria, particularly with any witnessed apnoea or significant daytime sleepiness. Anyone with treatment-resistant hypertension, new atrial fibrillation under 60, or unexplained pulmonary hypertension. Anyone whose partner has observed repeated apnoea events. Anyone on testosterone replacement with rising haematocrit. Safety-critical workers (HGV, PSV, pilot, railway) with any of the above.

Who probably does not need a full home sleep study

Young adults with occasional snoring, no daytime sleepiness, no other risk factors. Someone with clear primary insomnia symptoms and no apnoea predictors. Someone whose sleep complaint is clearly circadian (delayed phase, shift work) without other features.

The WatchPAT One home test

The WatchPAT One is a single-use, wrist-worn home sleep study device with a finger probe. You wear it for one night and post it back. It measures peripheral arterial tone, oxygen saturation, heart rate, and body position to produce a validated AHI plus sleep architecture estimates.

Evidence is strong for obstructive sleep apnoea: validated against in-lab polysomnography, accurate across mild, moderate, and severe disease. Not appropriate for suspected central apnoea, narcolepsy, REM-behaviour disorder, or paediatric sleep disorders.

Most patients who do the test sleep more normally than in a lab setting, producing a more representative result.

What happens after a positive test

We discuss the result with you, covering severity, the specific pattern (positional, supine-predominant, REM-predominant), oxygen saturation nadir, and symptoms. Treatment options include positional therapy, weight loss, mandibular advancement device, CPAP, and in some cases surgical referral.

The best treatment depends on the severity, your anatomy, the features of the apnoea, and your preference. CPAP remains the gold standard for moderate-to-severe apnoea but is not the only option and not always the right first step.

The honest bottom line

Apnoea is commoner than you think and often asymptomatic-feeling despite being clinically significant. The screening takes minutes. The home sleep study takes one night. Treating apnoea where it exists has meaningful long-term benefits and often immediate symptom improvements. If the symptoms in this article describe you, a structured assessment is worth it.

Ready to start?

If this article has made you think our assessment might help, the next step is a short consultation with one of our sleep-medicine doctors.

Begin your consultation at this link. Online with a WatchPAT One home study, or in person at Westfield London.