Sleep Apnea May Be Secretly Destroying Your Performance. Here Is How to Know.
I see a pattern in my practice that repeats itself more often than it should. A patient comes in frustrated. They are eating well, exercising consistently, managing their schedule as best they can, and still waking up tired. Their performance at work feels blunted. Their workouts feel harder than they should. Their patience is shorter than usual. They have attributed it to a busy season, to getting older, to the compounding demands of a high-pressure career. What they have not considered is that something is happening while they sleep, completely outside their awareness, that is quietly undermining everything else they are doing right.
Sleep apnea is that something, far more often than most people realize.
A Condition That Lives in the Dark
There is no routine screening for obstructive sleep apnea. Unlike elevated blood pressure or high cholesterol, which are caught incidentally in the course of a standard medical visit, sleep apnea requires a specific test that is almost never ordered unless a physician thinks to ask about it or a patient brings it up. Since the most telling signs occur during sleep, and the waking symptoms are the kind that busy, high-functioning people are well-practiced at attributing to something else, the condition can persist for years without anyone raising it.
A 2025 systematic review estimated that roughly one in three American adults has obstructive sleep apnea. The gap between that prevalence and the fraction who have actually been diagnosed is one of the more significant blind spots in preventive medicine.
What Is Actually Happening
Obstructive sleep apnea occurs when the muscles and soft tissues of the upper airway relax during sleep to the point of partial or complete collapse, repeatedly interrupting airflow. Each interruption triggers a brief arousal, usually too fleeting to register consciously, as the brain forces the respiratory system back online. In moderate to severe cases, this cycle can occur dozens or hundreds of times per night. The person sleeping through it has no memory of these arousals. What they experience is the cumulative effect: sleep that never reaches or sustains the deep, restorative stages the brain and body depend on.
Central sleep apnea, a less common variant, involves a failure of the brain's respiratory signaling rather than a mechanical obstruction. The two can coexist, and the distinction matters when selecting treatment. Most patients presenting with suspected sleep apnea have the obstructive form, which is the focus here.
Who Gets It
The cultural image of sleep apnea, an overweight, middle-aged man who snores loudly enough to rattle the windows, captures one presentation and misses most of the others. Obesity is a significant risk factor, but sleep apnea occurs across a wide range of body types, including lean, highly active individuals with no obvious predisposing factors. In my experience, this is exactly where the diagnosis gets missed most often.
The factors that actually predict risk include:
Upper airway anatomy: a narrow airway, recessed jaw, large tongue, enlarged tonsils, or a low-lying soft palate can create obstruction entirely independent of body weight
Sex: men develop obstructive sleep apnea at roughly twice the rate of women, though the disparity narrows considerably after menopause
Age: risk increases with age, though sleep apnea is not rare in adults in their thirties and forties
Neck circumference: increased soft tissue mass around the throat contributes to airway narrowing during sleep
Sleeping position: lying on the back allows gravity to work against the airway in ways that lateral sleeping largely prevents
Alcohol and sedatives: both relax the upper airway musculature, increasing the likelihood and severity of obstruction
Genetics: airway anatomy and respiratory control patterns during sleep have meaningful heritable components
The Symptoms That Get Explained Away
This is where I want to spend a moment, because the presenting symptoms of sleep apnea are almost never what prompt the diagnosis. The breathing pauses, the gasping, the intermittent choking, these happen during sleep and are either unobserved or normalized by a partner who has simply grown accustomed to them. What patients actually complain about, when they complain at all, looks like this:
Waking up tired after what should have been enough sleep. Feeling alert in the morning for an hour or two, then hitting a wall in the early afternoon. Noticing that their focus during demanding cognitive work is inconsistent in ways it did not used to be. Finding that their workout recovery is slower, their heart rate during exercise is harder to manage, and their performance metrics are trending in the wrong direction despite adequate training. Waking up at two or three in the morning for reasons they cannot explain, sometimes to use the bathroom, sometimes just restless, and then struggling to fall back asleep.
None of these symptoms, individually or together, would typically send someone directly to a sleep study. They sound too much like ordinary modern life. That is the problem.
The longer-term consequences of untreated sleep apnea extend well beyond fatigue. The repeated overnight drops in oxygen saturation and the chronic fragmentation of sleep are independent risk factors for hypertension, atrial fibrillation, coronary artery disease, stroke, insulin resistance, and cognitive decline. A 2025 meta-analysis found that nearly 37 percent of adults with obstructive sleep apnea showed evidence of cognitive impairment, rising to 44 percent in those with severe disease. In a longevity context, sleep apnea that goes untreated is not a sleep problem. It is a whole-body problem with a sleep-based cause.
The Test Is No Longer a Barrier
For a long time, diagnosing sleep apnea meant spending a night in a sleep laboratory wired to a polysomnography machine, which is inconvenient enough that many patients, and many physicians, quietly decided the threshold for pursuing it was higher than it needed to be.
That calculus has changed. Home sleep apnea testing is now clinically validated for most adults with suspected uncomplicated obstructive sleep apnea, and the devices available for it have become remarkably practical. The WatchPAT, which I recommend and use in my practice, is a wrist-worn device that measures peripheral arterial tone at the fingertip rather than airflow at the nose, making it significantly more comfortable than traditional home testing options that require nasal cannulas. Validation studies published in peer-reviewed journals have shown 89 to 94 percent concordance with in-lab polysomnography for moderate-to-severe obstructive sleep apnea, with approximately 96 percent sensitivity for detecting the condition overall. It is FDA-cleared and covered by most commercial insurance plans.
The patient wears the device for a single night at home. Setup takes about ten minutes. The data uploads automatically and is reviewed by a sleep physician. In most cases, that one night produces everything needed to confirm or rule out a diagnosis. For patients whose results are equivocal or who have features suggesting central apnea or other complex sleep-disordered breathing, in-lab testing remains appropriate. But for the majority of patients I evaluate, the home test is sufficient and removes the last practical reason to delay.
What Treatment Actually Looks Like Today
The other reason patients resist evaluation is an outdated image of what treatment entails. CPAP, the continuous positive airway pressure machine, has been the standard of care for decades, and it is genuinely effective when used consistently. The problem is that roughly 40 percent of patients prescribed CPAP do not use it regularly, and the reasons are understandable: older machines were loud, the masks were uncomfortable, and the overall experience was difficult to integrate into normal life.
The newer generation of CPAP and auto-adjusting APAP devices is substantially better. They are quieter, smaller, and the mask technology has improved considerably. For patients who remain unable to tolerate positive airway pressure in any form, the treatment landscape now offers meaningful alternatives. Custom oral appliances, fitted by a qualified dentist and designed to advance the mandible during sleep, are a well-established first-line option for mild to moderate disease and a viable alternative for more severe cases in CPAP-intolerant patients. Positional therapy, using devices that discourage supine sleeping, can be highly effective for patients whose apnea is predominantly position-dependent.
Weight loss, when relevant, produces clinically meaningful reductions in apnea severity. GLP-1 receptor agonists, which have demonstrated significant effects on body weight and metabolic health, are increasingly relevant here for appropriate patients. For moderate to severe obstructive sleep apnea in patients who have not responded to conventional treatment, hypoglossal nerve stimulation, a small implanted device that activates the tongue musculature during sleep to prevent airway collapse, has produced compelling outcomes in clinical trials and is now widely available.
The treatment of sleep apnea is, in 2025, an individualized conversation rather than a single prescription. What the right answer looks like depends on the type and severity of the apnea, the patient's anatomy, their lifestyle, and what they will actually use. What almost never applies anymore is the idea that the only option is a bulky mask and a machine on the nightstand.
What I Ask My Patients
In my practice, I ask about sleep quality in almost every comprehensive evaluation, and I have a low threshold for recommending a home sleep study. The questions are simple: Do you snore? Do you wake up during the night? Do you feel rested in the morning? Does your partner report that you stop breathing during sleep? Do you experience afternoon fatigue that feels disproportionate to what you have done?
A yes to more than one of these does not confirm sleep apnea, but it makes the case for finding out. The test is a single night at home. The upside of catching and treating a condition that may have been quietly limiting your health, your cognition, and your performance for years is substantial. The downside of ruling it out is a good night's sleep and a clean result.
If any of this sounds familiar, bring it up with your physician. It is a short conversation that can have a long impact.
Dr. Schraga is a physician at Crescendo MD and practices personalized preventive and longevity medicine on the San Francisco Peninsula.
