News of the official cause of death of iconic Star Wars actress Carrie Fisher (Princess/General Leia) has swept the Internet, leaving open many unanswered questions. The headlines suggesting Fisher’s death at age 60 was caused by obstructive sleep apnea (OSA) are giving many people reason to pause.
Can you actually die from sleep apnea?
It’s unclear whether Fisher had been diagnosed with and/or was actively treating her sleep apnea. We are attempting to learn more so that we may help educate others about diagnosis of and treatments for this very common medical condition.
What caused Carrie Fisher’s death?
Carrie Fisher died four days after suffering a heart attack during a flight from London to Los Angeles six months ago.
Her assistant shared in a recent interview that Fisher slept most of the flight and had suffered some respiratory events (apneas) during this time, which was considered normal for her. (It’s still unclear whether Fisher knew she had sleep apnea, according to this report from Forbes, which suggests if she did, she was potentially unaware of it and, therefore, not actively treating it.)
At the end of the flight, Fisher could not be awakened easily. When she did arouse, she began to vomit before slumping over and becoming unresponsive. These are symptoms consistent with heart attack in women.
Since then, family members, friends, and fans have wanted to know the specific cause of death. Fisher suffered from mental health problems and drug addiction throughout her life. Many assumed her death would be tied to drug use.
And to some extent, it has been. The Los Angeles County coroner’s office released its report last Friday, which revealed a number of factors which contributed to the popular actress’s death. While drug use was mentioned in the report, the announcement that sleep apnea and heart disease were major contributing factors has left many with new questions.
Monday morning, a more detailed analysis of Fisher’s death revealed the presence of multiple substances in her system at the time of death: cocaine, opiates, methadone, alcohol, and ecstasy. Ultimately, however, the cause of death was listed as “sleep apnea with other conditions: atherosclerotic heart disease, drug use.”
Is it possible to die from sleep apnea?
Some would argue that you might not actually die in your sleep from apnea. When the body senses it’s not getting enough oxygen during sleep, it forces an awakening. At this time, the breathing airways open and breathing resumes. Because of this mechanism, you stand no chance of suffocating in your sleep.
But that’s not the point. In fact, it’s like saying people don’t die from AIDS. No, they die from the inevitable complications that come from HIV. It’s true for people with diabetes, as well. No, diabetes does not kill a person outright; it’s a long process that results in poor quality of life, disability, pain, dysfunction, and a shortened lifespan.
Semantics don’t change the facts: mortality risks have been shown in clinical research to be higher in those who have sleep apnea. Sleep apnea disrupts circadian rhythms, imbalances body and brain chemistry, interrupts cardiac and respiratory function, elevates blood pressure, and speeds up the heart’s rate. When allowed to continue, untreated, it absolutely will lead to higher mortality for those who don’t treat it.
When you don’t treat sleep apnea
People with untreated sleep apnea (either because they don’t know they have it or they choose not to treat it):
- are more likely to have a heart attack (Sleep Health Heart Study results, 2001, American Journal of Respiratory Critical Care Medicine)
- have a 2 to 3 times higher risk for having a stroke (Sleep Health Heart Study results, 2010, American Journal of Respiratory Critical Care Medicine)
- face more than 3 times the risk of premature death (18 year follow-up of the Wisconsin Sleep Cohort, 2008, Sleep)
In addition, people who’ve had sleep apnea for up to 5 years have a 30 percent increase in their risk for having a heart attack or dying, according to research conducted at Yale University.
The more severe one’s sleep apnea, the higher the risk for either an attack or death. In the Wisconsin Sleep Cohort follow-up published in Sleep in 2008, 42 percent of the deaths in people with severe sleep apnea were due to heart disease. Severe, in clinical terms, is defined as having an apnea-hypopnea index (AHI) score of 20 or more respiratory events per hour.
Also, the risk of cardiac-related death was more than 5 times higher among those with untreated severe sleep apnea when compared with those who did not have sleep apnea.
Research findings published in The New England Journal of Medicine in 2005 also suggest that people with sleep apnea are more likely to die in their sleep due to sudden cardiac events, whereas most others who die of heart attacks (but who do not have sleep apnea) suffer these events during the day. Low blood-oxygen levels (and high carbon dioxide levels in the bloodstream) lead to surges in blood pressure, oxidative stress to the walls of the heart, and disruptions to the heart’s electrical rhythms.
Other celebrity deaths where sleep apnea was a factor
Fisher isn’t the only celebrity to have died due to health problems related to sleep apnea. Look at this Who’s Who list of sleep apnea sufferers who died of sudden cardiac death linked to this sleep breathing disorder:
- James Gandolfini (The Sopranos)
- Comedic actor John Candy
- Justin Tennison (The Deadliest Catch)
- Entertainer Harris Glenn Milstead (also known as Divine)
- Grateful Dead front man Jerry Garcia
- Singer-musician Israel Kamakawiwo’ole
- President William Howard Taft
- NFL player Reggie White
It’s also worth noting that deceased Supreme Court justice Anton Scalia, who passed away just a little more than a year ago, may have died as the result of failing to turn on his CPAP machine to treat his sleep apnea.
Living celebrities battling sleep apnea include:
- Comedians Rosie O’Donnell and Roseanne Barr
- Mythbusters personality Adam Savage
- Texas governor Rick Perry
- Basketball legend Shaquille O’Neal
- NFL quarterbacks Brett Favre and JaMarcus Russell
- TV personality Regis Philbin
- Star Trek icon William Shatner
- Comedian and magician Penn Jillette
- Author Anne Rice
- Daniel Lawrence Whitney (Larry the Cable Guy)
- Musician and American Idol judge Randy Jackson
- Musical legend Quincy Jones
Connecting the dots: heart disease, drug use, mental illness, and sleep apnea
Heart disease—a well-known comorbidity to sleep apnea—was clearly a factor in Fisher’s death. Other factors from the coroner’s report (such as drug use and mental illness) show negative correlations with sleep apnea as well.
Heart disease and sleep apnea
It’s well known in medical circles that an estimated 22 million Americans suffer from sleep apnea, with the vast majority of cases still undiagnosed. Some statistics on sleep apnea mortality estimate that at least 38,000 people die annually from heart disease directly complicated by sleep apnea.
Those people suffering from a heart condition might be well advised to take a look at their sleep health to better understand why, as a quarter of all deaths in the US are cardiac related. Heart disease kills more people than any other illness or condition, and for those who die as the result of it, at least 6 percent have been shown to have had sleep apnea, as well.
Women experience heart disease differently than men, as well. Two forms of cardiac problems more typical for women include nonobstructive coronary artery disease and atherosclerosis.
In Carrie Fisher’s case, atherosclerosis (hardening of the arteries) was the condition that led to her heart attack.
This form of heart disease occurs when substances including fats and cholesterol attach to artery walls, eventually stiffening and compromising the strength and elasticity of the heart. Coronary arteries lose their ability to transport blood efficiently into and through the heart, which is the body’s most critical muscle. Poor or lack of blood flow is a deadly consequence.
Sleep apnea, because it further stresses heart function and deprives the body of blood oxygen, can only worsen what’s already a bad situation.
Other factors that increase one’s risk for heart attack include smoking, drug use, and excessive drinking because they contribute, over time, to stiffened heart muscle, elevated blood pressure, and the buildup of plaque in the arteries.
Drug use and sleep apnea
Fisher was found to have cocaine, opiates, methadone, alcohol, and ecstasy in her bloodstream in her toxicology report. Using illicit drugs throughout one’s life can damage organs in a way that makes sleep apnea an eventuality.
- Cocaine use (or use of other “snorted” drugs) damages the structures of nasal and upper airways, leading to the collapse of these tissues during sleep
- Opiates are well known for depressing the respiratory system during sleep, when it relies on involuntary brain signaling to function. When the signals from the brain to the diaphragm are depressed by opioid medications, they lose strength, leading to reduced tone in the muscles that should be working together to support breathing.
- Alcohol, by itself, is a major respiratory depressant that should be avoided prior to sleep.
Substance abuse and sleeping disorders seem to go hand in hand as well. A National Institutes of Health study published in 2009 found that people with untreated sleep disorders often turn to drugs or alcohol to achieve sleep or maintain wakefulness during the day.
Unfortunately, substance use and abuse can also cause sleep disturbances, which only frustrates the matter.
Mental illness and sleep apnea
Fisher was a vocal mental health advocate. She’d suffered from bipolar disorder and may have used many of these drugs throughout her life in an effort at self medication.
It’s also important to note that sleep apnea, due to its impact on neurochemical function in the brain, can lead to mood disorders and depression. Though bipolar disorder is a separate medical condition, the addition of mood swings for people with sleep apnea caused by these chemical imbalances and/or related sleep deprivation cannot be discounted as having an additional negative impact on bipolar disorder.
All of this together composes a vicious cycle within the context of (likely) untreated sleep apnea:
- Sleep apnea can cause mood disorders and other mental health issues due to sleep fragmentation, fatigue, and deprivation
- Illicit drug use can also lead to mood, behavior disorders and risky behaviors such as substance abuse (to self medicate for problems with insomnia and daytime fatigue)
- Mental health issues that crop up as the result of untreated sleep apnea may lead to the use of drugs and alcohol, which can then worsen preexisting mental health problems
- For those with untreated sleep apnea, the cycle continues because of ongoing concerns related to insomnia, excessive daytime sleepiness, emotional fatigue, suicidal ideation, and other sleep-related mental health problems
What we can learn from Carrie Fisher’s death
“I know my Mom, she’d want her death to encourage people to be open about their struggles.” —Carrie Fisher’s daughter, Billie Lourd
Carrie Fisher’s death may be said to be the result of a perfect storm of factors orbiting the central problem of undiagnosed and/or untreated sleep apnea. SleepApnea.org is grateful to the Los Angeles County coroner’s office for stating the chief cause of death as sleep apnea. This effort gets to the heart of an ongoing need to discuss this dangerous, potentially lethal medical condition publicly.
It’s also likely Carrie Fisher herself—such an advocate for overcoming the stigma of mental health—would also advocate to remove the stigma surrounding snoring. Snoring is a major indicator for undiagnosed sleep apnea that should not go unnoticed by loved ones and family practitioners… and yet it does.
Fisher’s daughter, Billie Lourd, said in the wake of last week’s coroner’s report release, “I know my Mom, she’d want her death to encourage people to be open about their struggles.”
If you or a loved one you know snores loudly and frequently, has inexplicable and persistent high blood pressure, experiences gasping or choking at night while asleep, suffers from long-term daytime fatigue, or awakens with a dry mouth, raw throat or headache, please don’t discount the possibility you might have sleep apnea. Simple home testing can help rule the condition in (or out) and there are multiple approaches for treating this chronic medical problem.