Fractured sleep, Ambien, dial wingin' and other things

[robysue]

An update.

I've been paping now for 3 1/2 years. In that time, I've never gotten to where I've been sleeping soundly all night long, although when the insomnia is well under control, the wakes are few (as in 2 or 3) and short (as in less than 5-10 minutes) and I wake up feeling pretty decent.

But in the 3 1/2 years, the insomnia has waxed and waned and I've never really had more than about 5-6 months at a time with things really under control.

And right now? Things are not under control and I'm feeling pretty groggy when I wake up in the morning and I'm having a lot of problems functioning during the daytime. Things at work are taking way too long for me to complete simply because I stare at them without making much progress. Hubby, however, says my cognitive abilities have improved in the last 3 1/2 years, but it's not clear if he's comparing them to the pre-CPAP era or the immediate post-CPAP crash and burn of Fall 2010.

In the last 9 months, I've been battling the insomnia monster yet again. And in the last 5 months or so, the insomnia has been creepy up---in spite of taking Ambien 2-4 times a week. I've got a pretty consistent wake up time of 8:30 AM seven days a week and I'll usually be awake before hubby wakes me up. Bedtime fluctuates: I try to go to bed only when I'm sleepy enough to try to get to sleep without the Ambien. Time in bed fluctuates from around 5 hours to 7.5 hours: On nights where I'm not sleepy at 1:00 or 1:30, I'll often stay up until 2:00 or 2:30, by which time I usually am sleepy. On a "good" night, I can get to sleep (the first time) within about 10 minutes. On a "bad" night, I start to get uncomfortable (due to aerophagia mainly) after about 20 minutes and I'm still not asleep. Bad nights occasionally turn into disastrous nights where I get so frustrated that I wind up in a hissy-fit at 3:00 or 4:00 in the morning where I am a raving lunatic who is full of self-pity. I've not kept a detailed sleep log for the past 2 or 3 months in an effort to simply not focus so much attention on my sleep---in hopes that things might stabilize if I didn't worry so much. But it's not

Ambien takes the edge off the beginning of the night discomfort and it occasionally eliminates one or two of the middle of the night wakes. But even though I'm taking a mere 2.5mg, I usually feel "hung over" the day after I take an Ambien. If I take Ambien for 3 or 4 nights in a row, I also wind up with some pretty severe constipation.

Last night is a good example: We got home from skiing around 11:00 or so. By 1:00, I was feeling very tired, but on edge enough to know that the BiPAP was likely going to wake me up. So I took an Ambien at 1:00 and probably fell asleep within 5 minutes or so. There were a total of 4-6 wakes, but the troubling thing is that those wakes include two extended long restless periods. One restless period lasts about 20 minutes and the other about 40 minutes. It's not clear (from either my memory or the data) if those restless periods involve one long wake with some very light almost sleep or if they consist of multiple wakes that are just extremely close together. I got up at 8:30, so I was in bed for 7 1/2 hours, but I probably got around 6 to 6 1/2 hours of sleep. And this morning I've been (and continue to be) very, very groggy.

And in the last 3 or 4 months, the AHI also has been creeping up with a lot more nights in the 2.5- 4.0 range than in the 1.5-2.5 range. Snoring? Some nights the machine records a fair number (and sometimes hubby says there's no real snoring), other nights the machine records nothing or almost nothing (and sometimes hubby says he heard snoring.) Flow limitation index data while on Auto stays between 2 and 3 most nights. There's the occasional very good night AHI wise, but they are a lot less common than they were a year or so ago.

Because the AHI has been creeping up, I did do some experimenting with the settings on the BiPAP. I bumped my max IPAP up a bit (to 9 or 10 from my long standing max IPAP = 8) for a week or so. The 90% IPAP reading went up to 9 and the max EPAP started bouncing around 5.5-6 instead of 5.0-5.5. There was no real change in AHI or FLI or snoring. There was a huge negative change in the aerophagia. So after a week of torture, I backed back down to what's become my standard settings.

Having though long about it, I've decided that it was worth seeing if I might sleep better with a fixed IPAP/EPAP combination. For lots of reasons I decided to start with IPAP = 8 and EPAP = 5cm. [My titrated pressures on four different titration studies have been 9cm (fixed), 8/6, 7/4, and 8/5 (fixed bipap).]

But I cannot seem to settle down at the beginning of the night with pressure at 8/5 because it feels so high (and yes, I know how ridiculous that statement sounds), even though I have no real problems settling down (if I'm sleepy enough) with IPAP = 6 and EPAP = 4, the start of the Auto range. So I'm back to using the ramp. The PR machines do record events during the ramp time and the ramp pressures are the bottom part of my Auto range anyway, so I'm not worried that ramping will lead to an excessive number of events because the pressure is way too low.

On fixed pressure (even with extensive use of the ramp), the AHI seems to be down. It was way, way down last night---as in 0.28. The first night with fixed pressure, the reported AHI was well above 2, but all the events were recorded during a period when I was struggling to get to sleep (sans Ambien) and getting more and more frustrated with the aeriphagia; in other words, I'm not sure if any of those events are "real" or not; and once I finally did get to sleep for sure, there were no more events all night long. But the last two nights (with fixed BiPAP pressures) have triggered the return of pretty bad aerophagia and the aerophagia is clearly triggering longer, more miserable wakes. I'd like to continue the fixed BiPAP experiment for a full week, but I'm not at all sure my stomach will tolerate it.

I'm literally at my wits end. I know I need to email my sleep doc. But at this point I'm simply trying to sort out what to tell the sleep doc and what I want out of him. I know what I really want: I want to be able to get 6-7 1/2 hours of sleep without relying on the Ambien, with waking up no more than 2 or 3 times for no more than 5-10 minutes, I want to feel rested in the morning, and (more than anything else) I want to be fully functional before it's the middle of the afternoon even though I've been awake since 8:30 AM. But I also know that's asking for a magic bullet. The doc seems to have no idea what to do about the wakes, the overall AHI is technically not high enough to worry about, and (at this point), I'm technically getting 6 to 6. 5 hours of sleep most nights, and I feel worse rather than better as compared to where I was about 15 months ago.

Suggestions are welcome.

[Madalot]

Hey Robysue,

I wish I HAD some suggestions for you. But you're the smart one here and if you can't figure out what to do, I sure as heck cannot.

I hope someone smarter than myself can chime in and give you some input. Until then, know I'm thinking of you.

[49er]

I am so sorry to hear about your difficulties Roby Sue. Any ideas as to why?

I thought I read in the thread on diet that you going to a low carb diet as ordered by your doctor might had had a role. Did I read that right?

As an FYI, a low carb diet can definitely do that so perhaps this might be something to look into?

Best of luck.

49er



For many people, low carbing can bring on insomnia just as an FYI.

An update.

I've been paping now for 3 1/2 years. In that time, I've never gotten to where I've been sleeping soundly all night long, although when the insomnia is well under control, the wakes are few (as in 2 or 3) and short (as in less than 5-10 minutes) and I wake up feeling pretty decent.

But in the 3 1/2 years, the insomnia has waxed and waned and I've never really had more than about 5-6 months at a time with things really under control.

And right now? Things are not under control and I'm feeling pretty groggy when I wake up in the morning and I'm having a lot of problems functioning during the daytime. Things at work are taking way too long for me to complete simply because I stare at them without making much progress. Hubby, however, says my cognitive abilities have improved in the last 3 1/2 years, but it's not clear if he's comparing them to the pre-CPAP era or the immediate post-CPAP crash and burn of Fall 2010.

In the last 9 months, I've been battling the insomnia monster yet again. And in the last 5 months or so, the insomnia has been creepy up---in spite of taking Ambien 2-4 times a week. I've got a pretty consistent wake up time of 8:30 AM seven days a week and I'll usually be awake before hubby wakes me up. Bedtime fluctuates: I try to go to bed only when I'm sleepy enough to try to get to sleep without the Ambien. Time in bed fluctuates from around 5 hours to 7.5 hours: On nights where I'm not sleepy at 1:00 or 1:30, I'll often stay up until 2:00 or 2:30, by which time I usually am sleepy. On a "good" night, I can get to sleep (the first time) within about 10 minutes. On a "bad" night, I start to get uncomfortable (due to aerophagia mainly) after about 20 minutes and I'm still not asleep. Bad nights occasionally turn into disastrous nights where I get so frustrated that I wind up in a hissy-fit at 3:00 or 4:00 in the morning where I am a raving lunatic who is full of self-pity. I've not kept a detailed sleep log for the past 2 or 3 months in an effort to simply not focus so much attention on my sleep---in hopes that things might stabilize if I didn't worry so much. But it's not

Ambien takes the edge off the beginning of the night discomfort and it occasionally eliminates one or two of the middle of the night wakes. But even though I'm taking a mere 2.5mg, I usually feel "hung over" the day after I take an Ambien. If I take Ambien for 3 or 4 nights in a row, I also wind up with some pretty severe constipation.

Last night is a good example: We got home from skiing around 11:00 or so. By 1:00, I was feeling very tired, but on edge enough to know that the BiPAP was likely going to wake me up. So I took an Ambien at 1:00 and probably fell asleep within 5 minutes or so. There were a total of 4-6 wakes, but the troubling thing is that those wakes include two extended long restless periods. One restless period lasts about 20 minutes and the other about 40 minutes. It's not clear (from either my memory or the data) if those restless periods involve one long wake with some very light almost sleep or if they consist of multiple wakes that are just extremely close together. I got up at 8:30, so I was in bed for 7 1/2 hours, but I probably got around 6 to 6 1/2 hours of sleep. And this morning I've been (and continue to be) very, very groggy.

And in the last 3 or 4 months, the AHI also has been creeping up with a lot more nights in the 2.5- 4.0 range than in the 1.5-2.5 range. Snoring? Some nights the machine records a fair number (and sometimes hubby says there's no real snoring), other nights the machine records nothing or almost nothing (and sometimes hubby says he heard snoring.) Flow limitation index data while on Auto stays between 2 and 3 most nights. There's the occasional very good night AHI wise, but they are a lot less common than they were a year or so ago.

Because the AHI has been creeping up, I did do some experimenting with the settings on the BiPAP. I bumped my max IPAP up a bit (to 9 or 10 from my long standing max IPAP = for a week or so. The 90% IPAP reading went up to 9 and the max EPAP started bouncing around 5.5-6 instead of 5.0-5.5. There was no real change in AHI or FLI or snoring. There was a huge negative change in the aerophagia. So after a week of torture, I backed back down to what's become my standard settings.

Having though long about it, I've decided that it was worth seeing if I might sleep better with a fixed IPAP/EPAP combination. For lots of reasons I decided to start with IPAP = 8 and EPAP = 5cm. [My titrated pressures on four different titration studies have been 9cm (fixed), 8/6, 7/4, and 8/5 (fixed bipap).]

But I cannot seem to settle down at the beginning of the night with pressure at 8/5 because it feels so high (and yes, I know how ridiculous that statement sounds), even though I have no real problems settling down (if I'm sleepy enough) with IPAP = 6 and EPAP = 4, the start of the Auto range. So I'm back to using the ramp. The PR machines do record events during the ramp time and the ramp pressures are the bottom part of my Auto range anyway, so I'm not worried that ramping will lead to an excessive number of events because the pressure is way too low.

On fixed pressure (even with extensive use of the ramp), the AHI seems to be down. It was way, way down last night---as in 0.28. The first night with fixed pressure, the reported AHI was well above 2, but all the events were recorded during a period when I was struggling to get to sleep (sans Ambien) and getting more and more frustrated with the aeriphagia; in other words, I'm not sure if any of those events are "real" or not; and once I finally did get to sleep for sure, there were no more events all night long. But the last two nights (with fixed BiPAP pressures) have triggered the return of pretty bad aerophagia and the aerophagia is clearly triggering longer, more miserable wakes. I'd like to continue the fixed BiPAP experiment for a full week, but I'm not at all sure my stomach will tolerate it.

I'm literally at my wits end. I know I need to email my sleep doc. But at this point I'm simply trying to sort out what to tell the sleep doc and what I want out of him. I know what I really want: I want to be able to get 6-7 1/2 hours of sleep without relying on the Ambien, with waking up no more than 2 or 3 times for no more than 5-10 minutes, I want to feel rested in the morning, and (more than anything else) I want to be fully functional before it's the middle of the afternoon even though I've been awake since 8:30 AM. But I also know that's asking for a magic bullet. The doc seems to have no idea what to do about the wakes, the overall AHI is technically not high enough to worry about, and (at this point), I'm technically getting 6 to 6. 5 hours of sleep most nights, and I feel worse rather than better as compared to where I was about 15 months ago.

Suggestions are welcome.

[Loreena]

It seems to me you stop eating a long time before bed (with good reason, of course, to avoid aerophagia). But I think your brain needs some honey. I recently came across this article which contains:

[quote=]Try a tad of raw honey.

During the night, your brain uses a lot of energy. One efficient form of brain energy comes from sugar stored in your liver, called liver glycogen. Your brain taps your liver glycogen before hitting your muscle glycogen (stored sugar in your muscles), so having a little extra sugar before bed can help your brain function better at night. Raw honey is preferentially used to stock liver glycogen, so it is used first for brain function.

Raw honey is 22% better at making liver glycogen than the cooked, conventional stuff you’re likely to find at the supermarket. Taken without protein, a small amount of honey will raise blood glucose while you sleep too. I was skeptical of this trick when I first heard about it in The Honey Revolution, but I found it does work well as long as you don’t combine it with protein.

Especially when you’re doing BP Intermittent Fasting or eating very few carbs, you can get more deep sleep when you take a small amount of raw honey. At first I assumed that taking raw honey before bed would throw me out of fat burning mode, but as long as MCT oil was taken with the honey, enough ketones were produced to stay in fat burning mode. Take 1-2 teaspoons of raw honey before bed if it helps with your sleep.[/quote]

Source: The Top 6 Ways to Improve Your Sleep Using Food
https://www.bulletproofexec.com/the-top ... sing-food/

[Janknitz]

I thought I read in the thread on diet that you going to a low carb diet as ordered by your doctor might had had a role. Did I read that right?

Roby Sue has posted extensively on what she is eating. It may be lowER carb than SAD, but it is not low carb.

[newpapper]

My apologies if you covered this already, but do you take vitamin B12 and D supplements or have had their levels checked recently?

[Too tall]

Just take another ambien when you wake up half way thru the night. I just started on the cpap but I do know that as we get older, it sometimes becomes necessary to take things like ambien, Valium or Xanax. Also, regardless of what I take, it only gets me about halfway thru the night. I've had to split the dosage. Once you take it for a while you have to increase the dosage. I would use Xanax if it were me. Cheaper and works well.

[robysue]

Re DIET:
My current diet is lower in carbs than it used to be, but not (yet) strictly low carb. Some days it really is low carb and others it is not. Sleep problems do not seem to be correlated with diet, but I don't know for sure.

I've tried the raw honey trick in the past (about two years ago). Not sure it did anything, but honey has the advantage that it has no identifiable side affects. And at least it tastes good.

Vitamin B and D levels were checked about a year ago when the insomnia was spiraling out of control. Both were fine. I take 400mg of B2 for migraines and 2000IU of D every day. I've taken B12 in the past, but I'm trying to keep the number of vitamins and pills I take each day down to a number that does not bother me too much psychologically speaking. (Swallowing pills is an issue and always has been.)

Re SAD:
Seasonal affective disorder (SAD) plays a role, but I use a light box in the morning. With the return of the morning light, I've had to cut back on the light box because it can trigger migraines. The light box does a lot for me, but it does not eliminate too many multiple wakes, frequently caused by discomfort issues.

Re: a second dose of Ambien in the middle of the night:
I'm already waking up hung over from taking 2.5 mg of Ambien on the nights that I take it. The Ambien side affect is distinctly different than the tiredness from the insomnia. With the Ambien, it is difficult to wake up enough in the morning to become fully functioning. With the insomnia, I have no troubles waking up and functioning, but I'm tired and cranky all day. Neither is particularly "acceptable" and both interfer with what I need to get done on a daily bases. More Ambien in the middle of the night seems likely to increase the morning groggieness and the Ambien constipation.

Re: Xanax and other medication:
Medication that is primarily designed to affect moods or other psychological problems seem to trigger really bad side affects in me. And I'm not wild about randomly trying different meds in the hopes that something might work.

No one's mentioned these, but I'll add:
Re: Sleep hygiene:
I need to work on this. I've been back sliding on the sleep hygiene and it's catching up with me. But self-discipline is in limited supply since I've spent so much of it in the last 3 1/2 years complying with doctor's orders and after 3 1/2 years I still don't subjectively feel any better than before starting PAP in terms of the quality of my sleep. The amount of daily pain, however, is something that has improved since starting PAP, and that's really the only reason I keep on PAPing at this point.

Re: Headaches and TMJ:
The TMJ is under control, the headaches are problematic. The medication needed to take care of the migraine related vertigo triggers a large number of unacceptable side affects, but the vertigo is definitely has an adverse affect on the sleep.

Re: Exercise:
In October I fell on one of my nightly 3.5 mile walks. I messed up one knee and the limping then triggered significant back pain. The back pain has been addressed through physical therapy and it is now feeling better than it did before the fall. The knee continued to give me problems and I got cortisone shots in early Feb. It's feeling better and I start PT for the knee tomorrow. But walking has been problematic since Oct between the back, the knee, and the weather.

90 minute yoga classes twice a week are wonderful (most of the time) and skiing once a week are the main exercise. On days were I teach, I naturally get about 9000+ steps during the day without doing anything special; other days it's much less.

Re: Weight:
Weight has remained stable at between 105 and 112 for the entire last 12 months. I'm 5'1" so weight is not my problem.

[avi123]

An update.

And in the last 5 months or so, the insomnia has been creepy up---in spite of taking Ambien 2-4 times a week.
Suggestions are welcome.

Question,

How have you taken the Ambien, time and dose?

[kaiasgram]

robysue,
Just a grain of sand on the vast beach of possibilities -- What is your serum Vit D level? You mentioned it was "fine," but my understanding is that as we get older it's best for us to be at the higher end of the normal range. Best for sleep, best for mood, best for energy, immune system function... I've been trying to bust out of the low-normal end for a few years, and last year increased my daily Vit D intake to 3,000 IU and for the last several weeks I started on 4,000 IU. Blood test this week shows my level has dropped from 46 last year to 40. (For those who don't know, the normal range is considered to be 30-100 ng/mL.). So I am going to bump up my dose again. I've also read that taking D in the morning is better for sleep than taking it in the evening. I'll dig up the source if you're interested in more info on this.

You've tried more approaches and experiments to deal with your insomnia than many of us have. My heart goes out to you and although I don't have too much trouble with aerophagia anymore and I don't normally have a lot of wakeups, my sleep is garbage. I fall asleep and usually can get six hours before my first wake-up, but I am not getting restorative sleep. Even on mornings when I wake up and think I must have slept pretty well, I'm out of gas within a couple of hours. So for me pushing up the Vitamin D some more is a no brainer and inexpensive thing to try.

Hang in there.

[avi123]

But at this point I'm simply trying to sort out what to tell the sleep doc and what I want out of him. I know what I really want: I want to be able to get 6-7 1/2 hours of sleep without relying on the Ambien, with waking up no more than 2 or 3 times for no more than 5-10 minutes, I want to feel rested in the morning, and (more than anything else) I want to be fully functional before it's the middle of the afternoon even though I've been awake since 8:30 AM. But I also know that's asking for a magic bullet.

Comment,

I take .5 mg of Alprazolam (generic Xanax) and 300 mg Gabapentin at least 4 hours before going to sleep. The reasons for taking it are: musculoskeletal pain; arthritis; anxiety.

When going to sleep I take, but only half the time, 5 mg of Zolpidem (generic Ambien). My Nocturia averages 3 to 4 a night. I relate it to my borderline Diabetes (A1C = 6.5 max), and my OSA. Taking Flomax I could cut the Nocturia to one time, only. I sleep 6 to 7 hours. But IMO 6 hours should be enough for me, and I don't take naps. I have determined it from:

How much sleep
do you really need?

Eight hours seems to be the standard
for the required amount of sleep at
night. But does that number hold
true for everyone? It depends.
Infants and toddlers need the
most sleep — nine to 10 hours at
night plus naps during the day.

School-age children, including teens,
do best with nine to 11 hours a night.
Most adults require seven to eight
hours of sleep each night.

While older adults need about
the same amount of sleep as younger
adults, older adults tend to sleep
more lightly and for shorter periods
than do younger adults.

Do some people just need fewer
hours of sleep a night? Yes, it’s estimated
that somewhere between 1
and 5 percent of the population
sleep six hours or less a night without
ill effects. The need for less sleep
tends to run in families, as does the
need for more sleep, which suggests
a genetic basis for sleep duration.

Sleeping less than six hours — or
more than nine hours — has been
associated with increased risk of
health problems and a greater risk
of dying.

The most important factor in determining
how much sleep you need
is whether you routinely feel rested
during the day. Do you tend to feel
drowsy, or does your concentration
ability decline in low-stimulus situations,
such as long drives, reading,
watching television, talking on the
phone or completing desk work? If
this sounds like you, you’re likely
not getting enough sleep.


In my case the 6 to 7 hours of sleep means any of the following:

1) I go to sleep at midnight and after 3 Nocturias at 1:30; 2:30; 3:30 in which I fall back asleep right away I wake up at 5 a.m. Then I try to continue to sleep with the mask and CPAP for at least to 6:30. If I wake up at 6 a.m., I then try to continue with the mask and CPAP till 7 a.m.

2) I wake up at 3 a.m. and can't fall asleep with the mask for 20 min. I then try to fall asleep without the mask and without the machine, until I wake up again. I then put the mask on and sleep till after 6.

Many older adults who have trouble sleeping
(insomnia) also have one or more other conditions, such as heart disease,
musculoskeletal pain, lung problems, acid reflux disease, stroke, anxiety, depression
or pain caused by arthritis. In some cases, insomnia may be worsened
by the condition. In others, it may be part of the cause. The drugs used to treat
these conditions may contribute their own sleep-disrupting side effects.

All quotes from: Mayo Clinic health letter.

[SleepingUgly]

Have you tried Sonota instead of Ambien? It is shorter acting and might leave you less hung-over.

[John Chowder]

Hi robysue,

So sorry you are suffering from insomnia Have you ever tried natural remedies? I've had success with melatonin, 5-htp, and magnesium in the past. I've also used a natural pill called Alteril that's worked pretty well.

Hope you can get this solved!

[robysue]

An update.

And in the last 5 months or so, the insomnia has been creepy up---in spite of taking Ambien 2-4 times a week.
Suggestions are welcome.

Question,

How have you taken the Ambien, time and dose?

2.5 mg right before I go to bed. On a typical Ambien night that means I take it between 1:00AM and 2:00AM since my sleep window is 1:00 to 8:30 these days.

Any more than 2.5 mg leaves me hung over and not functional the next day.

[robysue]

robysue,
Just a grain of sand on the vast beach of possibilities -- What is your serum Vit D level?

I don't recall the exact figures, but I believe it was in the low 60s.

I was put on Vitamin D several years back when my Vit. D levels dropped to the low 30's or upper 20's. And yes, taking Vitamin D has made a difference.