Sleep Apnoea in High Performers: Most Cases Are Never Diagnosed

Longevity · 8 min read · For Executives

The symptom everyone attributes to work

The description is almost always the same.

You are tired in a way that a good night does not fix. You wake unrefreshed after seven or eight hours. Afternoons are a fight. Your concentration is worse than it was five years ago and you have quietly started to wonder whether that is just what your forties are. Your blood pressure has crept up despite reasonable behaviour. You are more short-tempered than you would like to be.

And every one of those has an obvious explanation available: the job. The travel. The hours. The stage of life.

Sometimes that is the whole story. But this particular cluster is also the classic presentation of a mechanical breathing problem during sleep, and the reason it goes unrecognised for years is that the explanation is already sitting there, ready to be used.

How common this is, and how often it is missed

Obstructive sleep apnoea is common in adults — considerably more common than most people expect — and the substantial majority of cases have never been diagnosed. The gap does not close at diagnosis either: a meaningful proportion of those diagnosed are never treated, and of those who start treatment, a large share discontinue it.

So the honest picture is not that sleep apnoea is a rare condition affecting a specific kind of person. It is a common condition that most of the people who have it do not know about.

Why this population is higher risk

Several of the factors that raise risk cluster in senior professionals in midlife.

• Age. Prevalence rises through the forties and fifties.
• Body weight. Weight gain — particularly around the neck and upper airway — is among the strongest modifiable risk factors, and midlife weight gain is common in this group.
• Sex. Prevalence is higher in men, though it is meaningfully underdiagnosed in women, partly because the presentation is more often fatigue and insomnia than the loud snoring stereotype. A woman describing exhaustion is less likely to be asked about her breathing.
• Alcohol. Alcohol relaxes upper airway muscle tone and fragments sleep architecture independently. Regular evening drinking — usually social and structured rather than heavy in the way people picture it — makes the problem measurably worse.
• Travel and irregular schedules. These do not cause apnoea, but they make it harder to notice, because poor sleep gets attributed to the hotel, the flight, the time zone.

There is also a specific group worth flagging: people with a history of significant head impacts, including former collision-sport athletes, in whom sleep-disordered breathing appears to be substantially underdiagnosed. More on athletic histories here.

What screening involves

Screening is not diagnosis, and the distinction matters more here than almost anywhere else.

Validated screening questionnaires — the most widely used being STOP-BANG — take a few minutes and ask about snoring, daytime tiredness, observed pauses in breathing, blood pressure, body mass index, age, neck circumference and sex. They are designed to be sensitive: they identify who should be tested, not who has the condition.

That is genuinely useful, because the single biggest barrier here is that nobody raises the question. A screening tool asks it.

What a questionnaire cannot do is tell you whether you have sleep apnoea, how severe it is, or what type it is. It has no access to what your breathing and oxygen levels actually do overnight.

Two other things worth knowing. If you sleep next to someone, ask them — a partner's report of snoring or observed pauses is one of the more informative pieces of history available. And consumer wearables that estimate sleep stages or oxygen saturation are not diagnostic instruments; a reassuring number from a watch does not rule anything out, and an alarming one does not establish anything either.

What we can do remotely, and what needs a sleep test

We will be precise about the boundary, because in this area a vague answer is a harmful one.

What we can do. Screen you with a validated instrument. Take a proper history — sleep, alcohol, weight trajectory, blood pressure, mood, medications. Run a full panel to identify or exclude the other common causes of this exact symptom picture, several of which are eminently treatable and frequently missed. And, where screening indicates it, tell you clearly that a sleep study is the appropriate next step and refer you.

Being clear about this is the point. A great deal of fatigue in this population gets treated as a hormone problem, a stress problem or a nutrient problem when the actual issue is that breathing stops repeatedly overnight — and treating the wrong thing wastes years.

Why it matters beyond tiredness

Untreated obstructive sleep apnoea is associated with a range of outcomes that go well past feeling flat: hypertension that is difficult to control, cardiovascular and cerebrovascular risk, impaired glucose regulation, mood disturbance, cognitive symptoms and — an underrated one for anyone who drives or makes consequential decisions — daytime sleepiness and impaired vigilance.

Some of these associations are stronger than others, and the literature is largely observational, which supports association more firmly than causation. But the direction is consistent enough that “I'll live with being tired” undersells what is being lived with.

The other reason it matters is diagnostic: untreated sleep apnoea will quietly sabotage the treatment of other things. Blood pressure that will not come down, glucose that will not improve, mood that does not respond, energy that does not return on hormone therapy — sleep-disordered breathing is a plausible reason for all of those, and it is worth excluding before concluding that a treatment has failed.

What treatment looks like

Treatment is not ours to deliver, but it is worth knowing what you would be walking toward.

Positive airway pressure therapy — PAP and its variants — remains the best-evidenced treatment for moderate to severe disease. It works when it is used, and the honest caveat is that adherence is a real problem: a large share of people who start it stop.

Oral appliances made by a dentist with sleep training can be effective for mild to moderate disease and are better tolerated by some people. Positional therapy helps a subset whose events cluster when sleeping on their back. Weight loss improves severity in people with excess weight, sometimes substantially — and where that is part of the picture, it is something we can help with, alongside rather than instead of the sleep evaluation. Surgical options exist for specific anatomical situations and are a specialist conversation.

Where this fits in your plan

If you are tired in a way that sleep does not fix, the useful sequence is: screen for sleep-disordered breathing, run a panel to identify the other common and treatable causes, and only then start attributing it to workload or to age.

It is a short conversation, and for a meaningful number of people in this group it is the one that explains several years. The executive hub covers what else this pattern of life does to a body.

Frequently asked questions

I do not snore. Can I still have sleep apnoea?

Yes. Snoring is common but not universal, and it is a less reliable indicator in women. Unrefreshing sleep, morning headaches, waking to urinate, difficult-to-control blood pressure and daytime sleepiness are all part of the picture.

I am not overweight. Does that rule it out?

No. Weight is a strong risk factor, not a requirement. Airway anatomy, jaw structure, nasal obstruction and age all contribute, and plenty of people with the condition are a normal weight.

Can a blood test detect sleep apnoea?

No. Bloodwork can identify or exclude other causes of the same symptoms — thyroid disease, anaemia, iron deficiency, B12 deficiency, glucose problems, hormone changes — which is genuinely worth doing. It cannot tell you what your breathing does overnight.

Can my smartwatch tell me?

No. Consumer wearables can flag patterns that might prompt a conversation, and some now include screening-type features, but they are not diagnostic devices. Do not use a reassuring reading to rule it out.

What if screening suggests I am at risk?

We will tell you plainly and refer you for a sleep study. We cannot diagnose sleep apnoea ourselves. It is a straightforward test and, in many cases, can be done at home.

Could this be why my hormone therapy has not helped?

It is a genuinely common reason for treatment not delivering what was expected. Untreated sleep-disordered breathing undermines a great deal of otherwise appropriate care, which is why we would rather rule it out early than late.

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