Sleep Apnea: The Hidden Reason High Performers Feel Like They're Running on Empty

Most people who have sleep apnea do not know it. That is not a minor oversight. It is a condition that, left untreated, quietly elevates the risk of cardiovascular disease, cognitive decline, metabolic dysfunction, and a broad range of consequences that accumulate over years while the person experiencing them attributes their symptoms to stress, aging, or simply being busy. It is a pattern I encounter regularly in concierge medicine, where the opportunity to ask deeper questions about sleep and recovery often surfaces what a standard annual visit would never catch. There is no routine screening for sleep apnea the way there is for high blood pressure or elevated cholesterol. People can live with it for years, often decades, without a diagnosis, because the most telling signs occur during sleep and the waking symptoms are easy to rationalize away.

A 2025 systematic review estimated that approximately 83.7 million adults in the United States, roughly one in three, have obstructive sleep apnea. Despite that prevalence, it remains substantially underdiagnosed. The gap between how common it is and how rarely it is caught represents one of the more consequential blind spots in standard medical care.

What Sleep Apnea Actually Is

Obstructive sleep apnea occurs when the soft tissues of the upper airway collapse repeatedly during sleep, partially or completely blocking airflow. Each episode causes a brief arousal, often too short to remember, as the brain forces the body to resume breathing. This cycle can occur dozens or even hundreds of times per night, fragmenting sleep architecture and preventing the deep, restorative stages of sleep the body requires.

A less common form, central sleep apnea, involves the brain failing to send the appropriate signals to the muscles that control breathing, rather than a physical obstruction. The two can coexist, and distinguishing between them matters for treatment. For the purposes of this post, obstructive sleep apnea is the primary focus.

Who Is at Risk

The association most people have with sleep apnea is an overweight, middle-aged man who snores loudly. That picture is real but incomplete. While obesity significantly increases risk, sleep apnea affects people of all body types, including lean, highly athletic individuals. Predisposing factors include:

• Anatomical features: a narrower airway, a recessed jaw, enlarged tonsils or tongue, or a naturally narrow palate can predispose anyone to airway collapse during sleep regardless of weight

• Male sex: men are approximately 1.5 to 2 times more likely to have obstructive sleep apnea than women, though the gap narrows significantly after menopause

• Age: prevalence increases with age, though sleep apnea is far from rare in younger adults

• Neck circumference: a larger neck circumference correlates with increased soft tissue mass around the airway

• Alcohol and sedative use: these relax the muscles of the upper airway, worsening obstruction

• Sleeping position: supine sleeping increases the likelihood of airway collapse due to gravity

• Family history: there is a meaningful genetic component to both airway anatomy and respiratory control during sleep

The Symptoms People Miss

Because the most dramatic manifestations of sleep apnea, the breathing pauses and the gasping or choking, happen during sleep, they often go unnoticed unless a bed partner observes them. The waking symptoms are subtler and frequently misattributed. They include:

• Persistent daytime fatigue or sleepiness, even after what appears to be a full night of sleep

• Frequent nighttime awakenings, sometimes attributed to needing to use the bathroom or general restlessness

• Morning headaches, often from overnight drops in oxygen saturation

• Difficulty concentrating or cognitive fogginess throughout the day

• Mood changes, including irritability and low-grade depression

• Reduced athletic performance and slower recovery from exercise

• Elevated resting heart rate or difficulty achieving target heart rate zones during training

For high-performing adults, these symptoms are particularly easy to dismiss. Fatigue is explained by a demanding schedule. Cognitive fogginess is attributed to stress. Reduced performance is assumed to be overtraining. The possibility that the problem is occurring during sleep, in a process the person has no conscious awareness of, often does not enter the picture until a physician raises it or a bed partner insists on an evaluation.

Why It Matters Beyond Being Tired

Fatigue and poor performance are significant enough consequences, but the downstream effects of untreated sleep apnea extend considerably further. The repeated overnight drops in oxygen saturation and the sleep fragmentation associated with untreated sleep apnea are independent risk factors for hypertension, atrial fibrillation, coronary artery disease, stroke, type 2 diabetes, and significant cognitive impairment. A 2025 meta-analysis found that the pooled prevalence of cognitive impairment among adults with obstructive sleep apnea was nearly 37%, rising to 44% in those with severe disease.

In a longevity medicine framework, untreated sleep apnea undermines virtually every other investment a patient makes in their health. Exercise, nutrition, stress management, and cognitive engagement all deliver diminished returns when the foundation of restorative sleep is compromised night after night.

Testing Has Never Been Easier

One of the most meaningful barriers to sleep apnea diagnosis has historically been the test itself. The gold standard, an in-lab polysomnography study, requires spending a night in a sleep center wired to monitoring equipment, which many patients find inconvenient, uncomfortable, or simply impractical. For years, this created a bottleneck in diagnosis that left many people undiagnosed not because they lacked access to clinical care, but because the test felt like more than the symptom warranted.

There is also a validity concern worth acknowledging honestly: many patients report that they simply do not sleep normally in a lab environment. Electrodes attached to the scalp, chest, and legs, a foreign bed, and the awareness of being monitored can significantly alter sleep quality and architecture. A result showing mild sleep apnea in someone who barely slept during the study, and who slept differently than they normally would, is legitimately difficult to interpret. This is not a trivial objection. It is one of the reasons home testing has become not just more convenient, but arguably more clinically informative for many patients: the data reflects how you actually sleep, in your own bed, under your normal conditions.

That barrier has largely been removed. Home sleep apnea testing has matured significantly and is now clinically validated for most patients with suspected obstructive sleep apnea. The WatchPAT device, which I use in my practice at Crescendo MD, is one of the most rigorously studied home testing options available. Rather than measuring nasal airflow through a cannula, it uses peripheral arterial tone measured at the fingertip, a technology that has been validated across multiple large studies. Validation data from peer-reviewed journals show 89 to 94 percent agreement with in-lab polysomnography for diagnosing moderate-to-severe obstructive sleep apnea, with approximately 96 percent sensitivity for detecting sleep apnea overall. It is FDA-cleared and accepted by most commercial insurance plans.

The test involves wearing a small wrist device and a finger probe for a single night at home. A reasonable question is whether the device itself disrupts sleep. In clinical practice and in the validation studies supporting the WatchPAT, this has not emerged as a significant issue. The wrist unit is comparable in size and weight to a standard watch, and the finger probe is lightweight and unobtrusive. Most patients adapt within minutes and report sleeping normally. This compares favorably to the in-lab experience, where the combination of an unfamiliar environment and multiple electrodes represents a far greater disruption to natural sleep. Setup takes roughly ten minutes, the data uploads automatically, and results are reviewed by a board-certified sleep physician. For the vast majority of patients with suspected uncomplicated obstructive sleep apnea, this is all that is needed to confirm or rule out a diagnosis.

Treatment Is Not What It Used to Be

The other barrier to seeking evaluation is the treatment itself. CPAP, the continuous positive airway pressure machine that has long been the first-line treatment for obstructive sleep apnea, carries a significant image problem. Bulky, noisy, and requiring a face mask that many patients find claustrophobic and uncomfortable, CPAP adherence is a genuine clinical challenge: studies suggest that approximately 40 percent of patients prescribed CPAP do not use it consistently. That image is also, to a significant degree, outdated.

Modern CPAP machines are quieter, smaller, and more comfortable than their predecessors. Auto-adjusting CPAP devices, which modulate pressure throughout the night based on real-time airflow data, have improved both efficacy and comfort considerably. For patients with mild to moderate obstructive sleep apnea, or for those who cannot tolerate CPAP, custom-fitted oral appliances that reposition the jaw and tongue to maintain airway patency are an effective and far more tolerable alternative, requiring nothing more than a small device worn in the mouth during sleep.

For patients whose sleep apnea is predominantly positional, occurring primarily when sleeping on their back, positional therapy devices can produce meaningful improvement without any machinery at all. Weight loss, including through GLP-1 medications in appropriate patients, has demonstrated clinically significant reductions in apnea severity. Hypoglossal nerve stimulation, a surgically implanted device that delivers mild electrical impulses to the tongue nerve during sleep, has emerged as a highly effective option for moderate to severe obstructive sleep apnea in patients who have not responded to or cannot tolerate conventional therapies.

The treatment of sleep apnea is no longer a one-size-fits-all proposition. The right intervention depends on the underlying cause, the severity of the disease, the patient's anatomy, and their preferences. What it almost always involves is a treatment that, when properly matched to the patient, is far less burdensome than the condition it is treating.

A Simple Ask

If you snore regularly, wake frequently during the night, feel unrested despite adequate hours in bed, experience unexplained daytime fatigue, or have noticed a decline in cognitive sharpness or athletic performance that you cannot attribute to another cause, sleep apnea belongs in the differential. The conversation with your concierge doctor or primary care physician takes minutes. The test, if indicated, can be done at home in a single night. And the potential returns on treating a condition that may have been silently undermining your health for years are substantial.

In personalized preventive care, few evaluations offer as much potential upside for as little inconvenience. If there is any question, the answer is to test.

Dr. Erik Schraga is a concierge physician at Crescendo MD, a longevity-focused concierge medicine practice serving the San Francisco Bay Area. He specializes in personalized preventive care, executive health, and longevity medicine for high-performing individuals and families.