Do you often feel unusually tired during the day, never quite alert even though you have slept long enough? Has your partner complained that your snoring is deafening, or that you even stop breathing in your sleep? These may all be warning signs of sleep apnea. According to research, an estimated 100,000 or more people in Hong Kong have sleep apnea, yet most of them have never been diagnosed. This article explains the symptoms and risk factors of sleep apnea in detail, and shows you how to use two internationally recognised self-assessment tools — the ESS daytime sleepiness self-assessment and the STOP-BANG questionnaire — so you can understand your level of risk straight away.
What Is Sleep Apnea?
Sleep apnea is a common sleep disorder in which breathing repeatedly stops or becomes shallow during sleep. The most common type is obstructive sleep apnea (OSA), which accounts for more than 90% of all cases. It is caused by the muscles of the upper airway relaxing during sleep, so that the airway narrows or even closes completely and air cannot pass freely into the lungs. Each apnea event can last from a few seconds to more than a minute, and in severe cases may happen hundreds of times a night.
When breathing stops, the brain detects the fall in blood oxygen and briefly rouses the person so that breathing resumes. These repeated micro-arousals seriously disrupt sleep architecture and prevent deep sleep, so that even after eight or nine hours in bed the person still wakes up exhausted. Over the long term, untreated sleep apnea greatly increases the risk of serious conditions such as high blood pressure, coronary heart disease, stroke, arrhythmia and type 2 diabetes, and may even lead to sudden death.
A less common type is central sleep apnea (CSA), caused by the brain failing to send the right signals to breathe, so that the breathing muscles make no effort to breathe. Some patients have both the obstructive and central types, which is known as mixed sleep apnea.
Night-Time Symptoms: Warning Signs While You Sleep
The night-time symptoms of sleep apnea are often noticed first by a partner or family member. If you sleep alone, these warning signs may go unnoticed for years. These are the most common night-time symptoms:
Heavy snoring
Snoring is the most typical and most common symptom of sleep apnea. The snoring of people with sleep apnea is usually very loud, and can even be heard outside the bedroom door or in the next room. It tends to follow an irregular pattern, suddenly falling silent for several seconds or tens of seconds (a pause in breathing), then resuming with a loud gasp or choking cough. If your partner describes your snoring as “loud enough for the neighbours to hear” or says “it’s frightening when you suddenly go silent”, sleep apnea should be strongly suspected.
Pauses in breathing or gasping
Your partner may notice your breathing stopping during sleep, possibly followed by violent gasping, choking or body jerks. These pauses in breathing may happen dozens or even hundreds of times a night, and their severity is measured by the Apnea-Hypopnea Index (AHI).
Frequent urination at night
What many people do not know is that needing to get up often at night to urinate (twice a night or more) is also a common symptom of sleep apnea. When breathing stops, the change in pressure inside the chest stimulates the heart to release atrial natriuretic peptide (ANP), which makes the kidneys produce more urine. If you often pass urine at night but urological tests show nothing abnormal, consider being assessed for sleep apnea.
Night sweats and dry mouth
People with sleep apnea often have unexplained night sweats. This is because the body releases large amounts of adrenaline when breathing stops, triggering the fight-or-flight response and causing a faster heartbeat and sweating. In addition, because the airway is blocked, patients tend to breathe through their mouth and wake with a very dry mouth and an uncomfortable throat.
Tossing and turning in your sleep
Because of repeated micro-arousals and obstructed breathing, patients often toss and turn in bed, constantly changing position. Some unconsciously prefer sleeping on their side, because on the back the tongue and soft tissue fall backwards more easily and block the airway, making apnea worse.
| Night-time symptom | What it is like | How it differs from ordinary snoring |
|---|---|---|
| Heavy snoring | Extremely loud, irregular, stopping and starting | Ordinary snoring is more even and continuous |
| Pauses in breathing | Snoring stops suddenly, resuming with a gasp after several seconds or tens of seconds | Ordinary snoring does not pause |
| Frequent urination at night | Getting up to urinate twice a night or more | Not related to urinary tract disease |
| Night sweats | Sweating that is not due to a warm room | Not related to hormones or infection |
| Dry mouth and sore throat | Especially noticeable on waking | Caused by breathing through the mouth for long periods |
Daytime Symptoms: The Hidden Effects During the Day
The effects of sleep apnea are not confined to the night; daytime symptoms often cause even greater problems for a person’s daily life, productivity and physical and mental health. These are the common daytime symptoms:
Excessive daytime sleepiness
This is the most prominent daytime symptom of sleep apnea. Patients find it hard to stay awake in quiet settings, with an irresistible urge to sleep in meetings, in front of the television, while reading or even while driving. In severe cases they doze off in the middle of a conversation or a meal. This sleepiness is different from ordinary tiredness; it is a strong urge to sleep that is hard to resist. Research indicates that people with untreated sleep apnea have 2 to 7 times the risk of a traffic accident compared with people without the condition.
Morning headaches
About half of people with sleep apnea wake in the morning with a headache, usually in the forehead or at both temples. This is caused by repeated oxygen deprivation during the night, which dilates the blood vessels in the brain and lets carbon dioxide build up. The headache generally fades within a few hours of getting up.
Poorer attention and memory
Poor sleep quality over a long period seriously affects cognitive function. Patients often complain of difficulty concentrating, a failing memory, lower productivity and impaired judgement. Some are misdiagnosed with depression or attention deficit hyperactivity disorder (ADHD) when sleep apnea is in fact the cause.
Mood swings and irritability
Chronic lack of sleep affects the brain’s emotional regulation centres, making patients prone to irritability, short temper, anxiety or low mood. Family members may notice that the person’s character seems to have changed, becoming impatient or often losing their temper. Research shows that people with sleep apnea have 2 to 5 times the usual risk of depression.
Reduced sexual function
Men with sleep apnea often experience a lower sex drive and erectile dysfunction, which is linked to the effect of long-term oxygen deprivation on blood circulation and hormone levels. Many patients do not realise this is in fact one of the symptoms of sleep apnea, and diagnosis and treatment are often delayed.
| Daytime symptom | How it shows | What it affects |
|---|---|---|
| Excessive daytime sleepiness | Unable to stay awake when things are quiet | Work, driving safety |
| Morning headaches | A dull ache in the forehead or temples | Quality of life in the morning |
| Poorer attention | Difficulty concentrating, poor memory | Productivity, ability to learn |
| Mood swings | Irritability, anxiety, depression | Relationships, mental health |
| Reduced sexual function | Lower sex drive, erectile dysfunction | Relationship with partner, quality of life |
Risk Factors: Who Is More Likely to Develop It?
Understanding the risk factors for sleep apnea helps with early awareness and prevention. These are the main risk factors recognised by the medical community:
Obesity and overweight
Obesity is the single most important risk factor for obstructive sleep apnea. Research shows that more than 70% of people with sleep apnea are obese or overweight. Fat around the neck narrows the airway, while abdominal fat restricts the movement of the diaphragm; both increase the risk of pauses in breathing. For each one-unit increase in body mass index (BMI), the risk of sleep apnea rises by about 10 to 20 per cent. It is worth noting that losing even 10 per cent of body weight may significantly reduce the severity of sleep apnea.
Sex and age
Men are 2 to 3 times more likely than women to have sleep apnea. This is linked to men’s tendency to store fat around the neck and upper body, and to the effect of male hormones on the airway muscles. However, women’s risk rises markedly after the menopause, narrowing the gap with men. As for age, the incidence of sleep apnea rises with age, and men over 40 and women over 50 are at higher risk.
Neck circumference and anatomy
People with a thick neck (more than 43 cm for men, more than 40 cm for women) have a noticeably higher risk of sleep apnea. Certain anatomical features also increase the risk, including enlarged tonsils, enlarged adenoids, a receding lower jaw, a small lower jaw, a large tongue, a deviated nasal septum and nasal polyps. These structural issues make the upper airway more likely to become blocked during sleep.
Family history
Although no research shows a direct hereditary link for sleep apnea, some of its risk factors are inherited, such as airway structure and body type. If a first-degree relative (a parent or sibling) has sleep apnea, your own risk is 2 to 4 times higher.
Other medical conditions
The following conditions are closely associated with sleep apnea: high blood pressure (about half of people with sleep apnea also have it), type 2 diabetes, cardiovascular disease, an underactive thyroid, acromegaly, acid reflux (GERD), and chronic nasal congestion or allergic rhinitis. Long-term smoking and drinking also increase the risk, because smoking causes inflammation and swelling of the airway, while alcohol and sleeping pills over-relax the airway muscles.
The ESS Daytime Sleepiness Self-Assessment: A Complete Guide (8 Questions)
The Epworth Sleepiness Scale (ESS) is an internationally recognised questionnaire developed in 1991 by the Australian doctor Murray Johns to assess a person’s level of daytime sleepiness in everyday life. The ESS is one of the most widely used sleepiness assessment tools in the world, and is used in Hong Kong and elsewhere for the initial screening of sleep apnea.
How to complete it
Based on how things have actually been for you recently, rate how likely you are to doze off in each of the eight situations below. Each is scored from 0 to 3:
- 0 — would never doze
- 1 — would rarely doze
- 2 — would sometimes doze
- 3 — would often doze
The eight ESS questions in full
| No. | Situation | Score (0-3) |
|---|---|---|
| 1 | Sitting and reading | 0 / 1 / 2 / 3 |
| 2 | Watching television | 0 / 1 / 2 / 3 |
| 3 | Sitting quietly in a public place (such as a cinema or a meeting) | 0 / 1 / 2 / 3 |
| 4 | As a passenger in a vehicle for an hour without a break | 0 / 1 / 2 / 3 |
| 5 | Lying down to rest in the afternoon | 0 / 1 / 2 / 3 |
| 6 | Sitting and talking to someone | 0 / 1 / 2 / 3 |
| 7 | Sitting quietly after lunch (without alcohol) | 0 / 1 / 2 / 3 |
| 8 | In a car, stopped for a few minutes in traffic | 0 / 1 / 2 / 3 |
Interpreting your ESS score
Add up the scores for the eight questions to get your total (minimum 0, maximum 24):
| Total score | Level of sleepiness | Recommendation |
|---|---|---|
| 0-7 | Normal | Daytime sleepiness is within the normal range |
| 8-9 | Mild sleepiness | Keep an eye on your sleep quality and improve your sleep habits |
| 10-15 | Moderate sleepiness | A sleep test assessment is recommended as soon as possible |
| 16-24 | Severe sleepiness | We strongly recommend seeing a doctor immediately and having a professional sleep test |
The STOP-BANG Questionnaire: A Complete Guide (8 Scoring Items)
The STOP-BANG questionnaire is a sleep apnea screening tool developed by Dr. Frances Chung’s team at the University of Toronto in Canada. Simple, quick and highly accurate, it is widely used by healthcare institutions around the world. The name STOP-BANG comes from the initial letters of its eight items, and the assessment is completed by answering eight simple yes/no questions.
S — Snoring
Do you snore loudly and often (louder than talking, or loud enough to be heard through a closed door)?
T — Tired
Do you often feel tired, sleepy or drowsy during the day?
O — Observed
Has anyone observed you stop breathing, choke or gasp during your sleep?
P — Pressure
Are you being treated for high blood pressure, or have you been diagnosed with it?
B — BMI (body mass index)
Is your body mass index (BMI) greater than 35?
A — Age
Are you aged 50 or over?
N — Neck circumference
Is your neck circumference large (more than 43 cm for men, more than 40 cm for women)?
G — Gender
Are you male?
| Letter | Item | Question | Yes/No |
|---|---|---|---|
| S | Snoring | Do you snore loudly and often (louder than talking, or loud enough to be heard through a closed door)? | Yes / No |
| T | Tired | Do you often feel tired, sleepy or drowsy during the day? | Yes / No |
| O | Observed | Has anyone observed you stop breathing, choke or gasp during your sleep? | Yes / No |
| P | Pressure | Are you being treated for high blood pressure, or have you been diagnosed with it? | Yes / No |
| B | BMI (body mass index) | Is your body mass index (BMI) greater than 35? | Yes / No |
| A | Age | Are you aged 50 or over? | Yes / No |
| N | Neck circumference | Is your neck circumference large (more than 43 cm for men, more than 40 cm for women)? | Yes / No |
| G | Gender | Are you male? | Yes / No |
How STOP-BANG is scored
Each “yes” answer scores 1 point and each “no” scores 0. Add up the eight scores to get your total (minimum 0, maximum 8):
| Total score | Risk level | Probability of OSA | Recommended action |
|---|---|---|---|
| 0-2 | Low risk | Low probability of moderate to severe OSA | Keep up healthy habits and monitor regularly |
| 3-4 | Intermediate risk | May have OSA | Consult a doctor and consider a sleep test |
| 5-8 | High risk | High probability of moderate to severe OSA | A professional sleep test is strongly recommended as soon as possible |
Using ESS and STOP-BANG together
The two tools have different emphases: the ESS mainly assesses how severe your daytime sleepiness is, while STOP-BANG assesses your overall risk of sleep apnea. We recommend using them together for a fuller picture of your sleep health. For example, a high-risk STOP-BANG score together with an ESS score above 10 means you are very likely to have sleep apnea and should see a doctor promptly. Conversely, even if your STOP-BANG score is not high, an abnormal ESS score may point to another sleep disorder that is worth investigating further.
When Should You See a Doctor?
If any of the following apply to you, we recommend seeking medical help as soon as possible:
Confirming a diagnosis of sleep apnea requires professional polysomnography (PSG) or a home sleep test. A sleep test records a range of data while you sleep, including brain waves, eye movement, muscle activity, heart rate, breathing airflow and blood oxygen saturation, so that it can accurately determine whether you have sleep apnea and how severe it is.
HomeCare Medical’s Sleep Test Services
HomeCare Medical has served the people of Hong Kong since 1993 and has more than 32 years of professional experience in sleep healthcare, making us one of Hong Kong’s leading specialists in sleep testing and sleep apnea treatment. We offer the following professional services to help you fully understand and manage your sleep health:
Home sleep test
Using the German SOMNOscreen™ plus wireless portable sleep monitoring system, you can complete the test in the comfort of your own home with no hospital stay. The system records a range of important data, including breathing airflow, blood oxygen saturation, heart rate, body position and snoring.
ESS and STOP-BANG assessment
Our professional staff will carry out a detailed assessment of your symptoms, including the ESS self-assessment and the STOP-BANG questionnaire, for an overall analysis of your level of risk.
Professional report interpretation
Once the sleep test is complete, we will give you a detailed report, and a professional will explain what each of the figures means.
Free professional consultation
Professional staff are on duty at all three HomeCare Medical locations (Lai Chi Kok, Tsim Sha Tsui and Causeway Bay) to provide free consultations.
One-stop follow-up
If sleep apnea is confirmed, we offer a full service including CPAP machine selection and fitting, titration tests and after-sales follow-up.
Frequently Asked Questions (FAQ)
Snoring does not necessarily mean you have sleep apnea, but heavy, regular snoring is one of its most common symptoms. If your snoring is extremely loud, or comes with pauses in breathing or waking up choking, a sleep test is recommended to confirm the diagnosis. Statistics suggest that about 30% to 50% of people who snore regularly have sleep apnea to some degree.
The ESS is an internationally recognised tool for assessing daytime sleepiness and is widely used in clinical diagnosis; its reliability and validity have been confirmed by a large body of medical research. However, it can only be used for initial screening and cannot replace a formal sleep test. If your score suggests a sleepiness problem, see a doctor promptly and have a professional sleep test to obtain an accurate diagnosis.
The STOP-BANG questionnaire has a maximum score of 8. A score of 0-2 is low risk, 3-4 is intermediate risk, and 5 or above is high risk, in which case a sleep test is recommended as soon as possible. Even with a score of only 3, you should seek a professional assessment if you have clear symptoms (such as severe daytime sleepiness or pauses in breathing noticed by your partner). Research shows that the probability of moderate to severe sleep apnea rises significantly in people who score 3 or above on STOP-BANG.
Sleep apnea does not generally go away on its own. Mild, obesity-related sleep apnea may improve with weight loss, but moderate to severe cases usually need ongoing treatment, such as using a CPAP machine. Going untreated may increase the risk of serious complications such as high blood pressure, stroke and heart disease. Early diagnosis and treatment are crucial to a better outcome, so do not put off seeking medical help.
Summary
Sleep apnea is a common but easily overlooked serious condition. Knowing its symptoms and risk factors, and using the ESS questionnaire and the STOP-BANG questionnaire early for self-assessment, is the first step in protecting your sleep health. If the results suggest you are at higher risk, do not hesitate — book a professional sleep test as soon as possible. With 32 years of professional experience, HomeCare Medical offers a one-stop service from initial assessment and sleep testing to treatment follow-up, with free professional consultations at all three locations. Contact us or visit a showroom to find out more.
HomeCare Medical’s professional team offers free sleep consultations and can help you complete the ESS and STOP-BANG self-assessments. After the assessment, we can also arrange a professional home sleep test, so you can have hospital-grade sleep diagnostics at home.