Sleep Apnea
President Taft
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Sleep apnea can be hard to recognize
Over 90% of persons with sleep apnea are not diagnosed. The reasons include:
     • The symptoms of sleep apnea are often vague.
     • Symptoms develop slowly, so patients may not realize they have become sick.
     • Knowledge of the disease by physicians is low.
     • The test normally used to diagnose sleep apnea is expensive and specialized.

Sleep apnea occurs commonly. It is therefore important that you be alert to its symptoms. If you have suspicions, ask your doctor.

Taft's illness was not recognized for over a century. In his era, just a few physicians understood the significance of excessive sleepiness in obese persons. Taft knew some of these physicians. Taft realized that his obesity made him sleepy, but didn't know why. Only at his heaviest weight did he note: "I was nervous and fretful, and for a month I found it hard to sleep."

Sleep apnea can affect job or school performance
Everyone knows that missing a night of sleep, or sleeping poorly for several nights, makes thinking difficult the next day.

People with sleep apnea have poor-quality sleep -- every night. This hurts their mental functioning. For example, an important study looked at first graders who were near the bottom of their class. It found that 25% of these students had sleep apnea. After treatment for sleep apnea, the students' grades went up significantly.

Before he developed sleep apnea, Taft's mind was described as "clear and strong." As President (the period when his sleep apnea was worst) Taft was described as "thinking with only half of his normal clarity" and as "mentally enfeebled." After the Presidency, Taft rid himself of sleep apnea and entered a period of "exceptional intellectual productivity." One Senator wrote of the ex-President, "If Mr. Taft could have done as well when in office as he talks while out of office he would never have been defeated for re-election." Taft's dislike of Presidential politics complicates the interpretation of such evidence.

Sleep apnea can be dangerous if untreated
Severe sleep apnea can cause sudden death during sleep and can increase the risk of high blood pressure. It has also been linked to abnormal heart rhythms, heart failure, stroke, coronary artery disease, diminished libido, and problems related to anesthesia. Sleep apnea also increases the risk of accidents, to the same degree as alcohol according to one study.

It is generally thought that treating sleep apnea reduces the risks attributable to the disease.

While Taft was President, his systolic blood pressure was 210 mmHg. It was further reported that "he pants for breath at every step" while walking, a sign that his heart had likely become weakened. Taft's deteriorating physical appearance as President sparked rumors he was seriously ill. Later in life Taft developed the abnormal heart rhythm known as atrial fibrillation. Although atrial fibrillation is associated with sleep apnea, we do not know if Taft's case was caused by his earlier sleep apnea.

Sleep apnea can be embarassing if untreated
A more enlightened world would not taunt people about their medical problems. The sad truth is, it happens.

Taft's obesity was the subject of countless jokes and taunts. His sleepiness caused more embarassment for his intimates than for Taft himself. Taft's closest aide, Major Archibald Butt, felt a duty to keep Taft awake in public, and he took this duty as seriously as his duty to protect the President's person. Butt would stay near Taft in public, slyly awakening him with a hard nudge, by dropping an object, or with his "old trick," a coughing spell. During one church service, Butt thought his frequent coughing would make people suspicious he had tuberculosis .

It's not normal to be tired always
Words like "tired," "sleepy," and "fatigued" mean different things to different people. For some people, tired means the same as sleepy. For others, it does not. The clearer you can be when talking to a doctor, the more likely he or she will be able to correctly interpret your symptoms. Many many disorders cause tiredness.

Sleep should be refreshing. If sleep duration has been adequate, and sleep is not refreshing, then something is not right.

Most people with sleep apnea fall asleep quickly. Other conditions will also cause people to fall asleep quickly. Paradoxically, about 10% of patients who complain of insomnia will actually have sleep apnea.

Taft always seemed to be tired and always to crave rest. He was not burning the candle at both ends: he spent enough time in bed. His sleep apnea made his sleep non-refreshing. Early in his disease, Taft misinterpreted the cause of his sleepiness. He was then living in the Philippines, and thought that the tropical environment made everyone sleepy. Some years later Taft realized that his sleepiness and his weight were related.

Sleep apnea is linked to weight
For the most common type of sleep apnea, 70% of cases are linked to weight. The greater the weight, the more likely sleep apnea becomes. It appears that each of us has a unique threshold weight where sleep apnea begins, all other factors being equal. Sometimes just a few extra pounds can make the difference.

Anyone can develop sleep apnea, however, no matter their weight. In children, enlarged tonsils or adenoids can contribute. In some people, the anatomies of the jaw and upper airway are disproportionate. Sleep apnea may also accompany certain medical conditions. For example, about half of patients with heart failure have sleep apnea.

It appears that Taft would develop symptoms of sleep apnea when his weight got close to 300 pounds. Except for a period of successful dieting about 1906, he weighed 300+ pounds from about 1901 to 1913. (The 1901 date is uncertain because Taft purposely did not weigh himself in the Philippines -- he thought the results would displease his wife.)

Sleep apnea is treatable
The most common type of sleep apnea can be treated by a breathing mask ("CPAP"), by oral appliances, by weight loss, by surgery, or sometimes by nasal decongestants or a change in sleeping position. Each type of treatment has its advantages and disadvantages.

The type of treatment best suited to an individual is best decided in consultation with the individual's physician, dentist, and family.

Taft treated his sleep apnea by losing weight. Of course, he did not know the precise link between his weight and his sleepiness, but he knew that he was much more alert when he weighed less. Taft also engaged in regular exercise, especially golf, and he had a personal trainer. It is likely that the weight loss had a much greater benefit to Taft than did the exercise.

You can be a high achiever and have sleep apnea
Physicians know that many jobs with impressive titles, such as CEO or Chairman of the Board, can be filled, and sometimes filled adequately, by persons who develop dementia.

Sleep apnea normally causes less intereference with thought than dementia. We should not, therefore, be surprised when people in positions of power and influence reach and retain their positions even when they have sleep apnea.

Taft is arguably the highest achiever in the history of the United States. No other man has been both President and a Supreme Court Justice. As if that were not enough, Taft was virtually the ruler of a second country -- the Philippines -- when it was a United States possession and he was its first civilian governor. Taft's most impressive accomplishment, however, may have been supervising construction of the Panama Canal while Secretary of War .

Snoring is a sign of sleep apnea
Snoring and sleep apnea go together, but they do not go together perfectly. Most persons with sleep apnea snore, but some do not. Most persons who snore do not have sleep apnea, but some do.

Snoring cannot be used to decide whether a person does or does not have sleep apnea. Snoring is a sign that the sleeper is at higher-than-normal risk to have sleep apnea.

In all but the rarest cases, the sound made by snoring is not itself harmful to the sleeper. Of course, it may severely disrupt the sleep of others.

Taft's wife does not mention snoring in her 1886 honeymoon journal, but describes him snoring as early as 1900. Taft was displaying signs of excessive sleepiness even then. There are descriptions of Taft snoring in the 1904-1908 time frame, and several accounts of him snoring as President. Taft would even snore when asleep sitting up, suggesting that he had severe snoring when lying down. Partial sleep deprivation worsens snoring, so it is interesting that Taft and his wife would use separate bedrooms in the White House when "he was particularly tired."

You can "sleep well" and still have sleep apnea
Many persons with sleep apnea do not suspect they are sleeping poorly at night. This belief is understandable. Persons with sleep apnea often fall asleep quickly, with no tossing and turning. Although their brain may briefly wake up on hundreds of occasions during the night, none of this is remembered the next morning.

Physicians therefore find it very useful to have another person's description of sleep. Breathing problems and frequent motions which are not apparent to the sleeper may be readily observed by someone else.

Throughout his 10+ years of sleep apnea, Taft rarely complained about his night-sleep. Before air conditioning was installed in the White House, Taft several times had difficulty sleeping in hot, humid summer weather. This can be considered normal. Despite the pressures of the Presidency, he was sleepless on only a few other occasions. Upon leaving the White House at his maximum lifetime weight, Taft was "nervous and fretful and for perhaps a month ... found it hard to sleep." It is not clear what this could have been.

Sleep apnea can run in families
Researchers have found that sleep apnea runs in some families. Without doubt, part of the reason is genetic, and part is environmental.

For example, body-weight is an important factor in sleep apnea, and body-weight in a family is determined both by genes and by the shared environment. It seems likely that anatomy of the jaw and upper airway would be more influenced by genes than environment, but knowledge of this area is very limited. Certainly, there are additional factors that science has yet to identify.

In Taft's case, this lesson is a big stretch. When Taft was 11 months old, his mother wrote to his father: "Even when you found time to read to me I found it difficult to listen with unbridled attention." Of course, the mother of an infant has many reasons for her mind to wander, or to be sleepy, and we cannot make a strong case that Taft's mother had sleep apnea. Sleep apnea is least commmon in women of childbearing age, but it does occur. Regarding anatomy, Taft's mother described her infant son as having a "short upper lip making the triangular fish-shaped mouth common to the babies of our family, but his chin is peculiar and just like his father's and grandfather's." Taft's daughter had the same mouth shape. . The significance of this is unknown. There has been no other information to suggest anyone in Taft's family had sleep apnea.

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Last modified 15:29 Pacific on 21 Jun 2004.