No help for lack of rem sleep and PLMD?

[Masta]

I had my first visit with pulmonologist/sleep doctor since I started cpap 3rd Aug 2015 (approx 2.5mths).

Because I haven't had a miraculous recovery or haven't felt any different since starting cpap therapy, sleep doctor thinks I should quit cpap therapy. MY AHI was 9.3 while sleeping on my back, and 4.5 while not sleeping on my back total AHI of 5.1 (so mild OSA), I had no rem sleep during the ovrnight sleep test that was done without cpap therapy. I still feel exhausted. I know that cpap therapy can take a long time before you feel any results, sometimes it may never happen.

cpap doctor would not address that I had no rem sleep during my sleep test, my test showed little Stage 3 NREM sleep. I informed the doctor I'm a light sleeper and wake exhausted. He will not prescribe any sleeping pills or any other advice for the lack of rem sleep. he says there is nothing that can be done for lack of rem sleep.

I kept on suggesting the doc to address both issues the lack of rem sleep and the PLMD, he said because I'm on 10mg of prozac that could be the cause of the PLMD.

I said I have had PLMD when I wasnt on Prozac, he asked me how would I know that, I said coz my hubby sees me kicking in my sleep on and off Prozac.

I said to the doctor im going to stay on cpap, because heart issues run in my family and I have tachycardia (im on medication for it), I want to prevent OSA.

sleep doctor said the only way to tell if I have PLMD while on cpap therapy is to do another sleep test. i said lets do it. so he ordered a sleep test with cpap therapy titration this time.

can something be done for no rem sleep? or lack of NREM? I know there are medications available for PLMD, the sleep doctor is hesitant to give me any meds coz im on medications for other problems.

My full sleep report is in the url below my post

Polysomnogram:

Sleep quality: The sleep onset was 11.7minutes normal being 10-30 minutes. She slept for a total of 210.5 minutes out of a possible 382.3 minutes, resulting in a sleep efficiency of 55.1%, normal being greater than 90 percent. The awake time after sleep onset (WASO) was 160.1 minutes. She had mild sleep fragmentation. She had 67 arousals during the night, resulting in an arousal index of 19.1 arousals/ hour of sleep. Most of these arousals were caused by limb movements. She also had frequent periods of prolonged wakefulness.

Assessment: Obstructive sleep apnea. This patient had mild sleep apnea. Her AHI was 5.1 events/hour and her Sp 02 dropped to as low as 82%. Her AHI worsened to 9.3 events/hour while sleeping in the supine position, compared to only 4.5 events/hour when sleeping in the non supine position. Her sleep apnea contributed to sleep fragmentation, her arousal index was 19.1 arousals/hour of sleep. A split night study was not possible, according to our protocol, as she did not demonstrate moderate to severe apnea prior to 2am.

Periodic limb movement disorder: This patient had 191 limb movements during sleep, which led to 34 arousals. The periodic limb movement index was 24.8 limb movements/hour.

Decreased REM sleep: This patient was unable to obtain any REM sleep. where it is normal to spend between 20-25% of sleep time. This can be caused by anything that interrupts or fragments sleep such as pain or sleep apnea, but it also can be caused by medications, most commonly anti-depressants/psychoactive drugs.

Decreased sleep efficiency: This patient slept for only 55.1% of the available study time. It is normal to sleep greater than 90% of the study. It is not uncommon for patients to struggle during their first night in the sleep lab.

**Recommendations**:
Obstructive sleep apnea. This patient has mild sleep apnea and DOES qualify for CPAP treatment, however, a more conservative approach could be pursued. Often simply avoiding sleeping in the supine position while maximizing nasal airflow is very effective. using a mandibular advancement device may also be effective. Aggressive weight loss is usually effective if the patient has gained weight in the face and the neck. These options should be discussed with the patient.

Periodic limb movement disorder: This patient’s limb movement disorder should be treated only if her excessive daytime sleepiness does not improve with the treatment of her sleep apnea.

Decreased REM sleep: This will hopefully improve with the treatment of her underlying breathing disorder. An evaluation for nocturnal pain or discomfort would be helpful. Adjusting any centrally active medications may also be helpful.

Decreased sleep efficiency: If this patient does have regular struggles with insomnia, it is important to improve sleep hygiene, control of pain or discomfort, and treat any underlying anxiety disorder.

[Wulfman...]

I suspect that this may be part of your problem.

Auto 8-16.

How do you know you're not getting any REM sleep now?
You can actually "dream" in any sleep stage.

Your Auto settings (pressure increases) may be bumping you out of your needed sleep stages as your breathing changes during the night......keeping you out of your needed sleep stages and keeping you in lighter ones.......resulting in your feeling "exhausted".

Are you monitoring your therapy with software (like Sleepyhead)?


Den

.

[Masta]

I suspect that this may be part of your problem.

Auto 8-16.

How do you know you're not getting any REM sleep now?
You can actually "dream" in any sleep stage.

Your Auto settings (pressure increases) may be bumping you out of your needed sleep stages as your breathing changes during the night......keeping you out of your needed sleep stages and keeping you in lighter ones.......resulting in your feeling "exhausted".

Are you monitoring your therapy with software (like Sleepyhead).

Den,
I am monitoring my sleep with sleepyhead. Im new this cpap therapy. I dont know what to look for when viewing sleepyhead. My original prescription was 4-16, I was on that setting for a month. The 4 was too low when I started on cpap every night, i couldnt breath properly so i informed my doctor and he bumped it up from 4-16 to 8-16.

[Pugsy]

SSRI meds are well known to mess with sleep architecture....especially known to suppress REM
and potentially make restless leg worse.

http://www.ncbi.nlm.nih.gov/pubmed/15892588

http://www.psychiatrictimes.com/sleep-d ... ants-sleep

While your meds may not be totally responsible for your issues it is possible that they are playing a role.
Research your meds deeply for known side effect and how they affect sleep architecture.
Couple of links above...read them and then do some more research.

[Wulfman...]

Den,
I am monitoring my sleep with sleepyhead. Im new this cpap therapy. I dont know what to look for when viewing sleepyhead. My original prescription was 4-16, I was on that setting for a month. The 4 was too low when I started on cpap every night, i couldnt breath properly so i informed my doctor and he bumped it up from 4-16 to 8-16.

OK. What is your (average) 90/95% pressure? If it's a bit higher than the 8 cm. (minimum), then I think it would be worthwhile to increase it.
Try looking at your reports and see if you can find periods of time where your events are minimal or non-existent.......and try to note what pressure it's at. You could either narrow your pressure range to that pressure or try straight (CPAP) pressure at that pressure.

Bottom line is that you're going to have a hard time feeling rested if you're being bounced around all night.

Note: I also read Pugsy's post and agree the meds could be problematic, too. Which may be another reason to try straight pressure.......it would be a "constant" in trying to single out what specifically is disrupting your sleep. Or, said another way, try to eliminate as many "variables" as possible.


Den

.

[Masta]

Den,
I am monitoring my sleep with sleepyhead. Im new this cpap therapy. I dont know what to look for when viewing sleepyhead. My original prescription was 4-16, I was on that setting for a month. The 4 was too low when I started on cpap every night, i couldnt breath properly so i informed my doctor and he bumped it up from 4-16 to 8-16.

OK. What is your (average) 90/95% pressure? If it's a bit higher than the 8 cm. (minimum), then I think it would be worthwhile to increase it.
Try looking at your reports and see if you can find periods of time where your events are minimal or non-existent.......and try to note what pressure it's at. You could either narrow your pressure range to that pressure or try straight (CPAP) pressure at that pressure.

Bottom line is that you're going to have a hard time feeling rested if you're being bounced around all night.

Note: I also read Pugsy's post and agree the meds could be problematic, too. Which may be another reason to try straight pressure.......it would be a "constant" in trying to single out what specifically is disrupting your sleep. Or, said another way, try to eliminate as many "variables" as possible.

Den.

Den, My 90% pressure is 9.16 over the last 7 days 9.32 over the last 30 days. 9.10 over the last 6 mths (looking on the statistics page of sleepyhead).

Pugsy, thank you for the url's, I wil do some research.

[Wulfman...]

Den, My 90% pressure is 9.16 over the last 7 days 9.32 over the last 30 days. 9.10 over the last 6 mths (looking on the statistics page of sleepyhead).

Pugsy, thank you for the url's, I wil do some research.

OK. If you still wish to use APAP mode in a range of pressures, bump your minimum up to 9 for awhile and see if the 90% keeps increasing. Also, be mindful of how much your pressure is bouncing around all night. Also the same with the amount of Flow Limitations and Snores. Those are virtually the only two things that typically cause the pressures to increase with an APAP.

If you wish to try straight pressure, set it at 9 cm. (either in CPAP mode or set min and max to same pressure in APAP mode).
Then monitor it for a number of nights and see how that treats the events and how you feel. You can always do small increments if need be till you find the "sweet spot".


Den

.

[Masta]

Den, My 90% pressure is 9.16 over the last 7 days 9.32 over the last 30 days. 9.10 over the last 6 mths (looking on the statistics page of sleepyhead).

Pugsy, thank you for the url's, I wil do some research.

OK. If you still wish to use APAP mode in a range of pressures, bump your minimum up to 9 for awhile and see if the 90% keeps increasing. Also, be mindful of how much your pressure is bouncing around all night. Also the same with the amount of Flow Limitations and Snores. Those are virtually the only two things that typically cause the pressures to increase with an APAP.

If you wish to try straight pressure, set it at 9 cm. (either in CPAP mode or set min and max to same pressure in APAP mode).
Then monitor it for a number of nights and see how that treats the events and how you feel. You can always do small increments if need be till you find the "sweet spot".


Den

.

Den, I do not know how to change the settings on my machine. Am I allowed to do that, will my doctor get annoyed? Ive taken 2 screenshots of the last couple of nights.

[yoshi]

PLMD stinks. I'm sorry you're going through that.

I'm no doc, but mine has told me that PLMD is caused by neuro but can be triggered by a lot of things. We investigated low iron levels (nope, mine are high for a woman). My antihistamines guaranteed an especially active night... I went the length of doing immunotherapy so I wasn't quite as dependent on antihistamines. Adding exercise was a chicken and egg problem (balancing the right amount of exercise but being too exhausted to do the requirement). One thing that did consistently help me was magnesium supplements but my digestive tract hated it... My body was fighting sleep however it could. I was put on a lot of different Parkinson's medications, but in the end the doctor said basically I went through enough torture so we gave up... Lunesta was my work around. It didn't fix my problem, it just allowed me to get a little bit of sleep between the irritating part and the actual kicking myself awake (and making my dog yipe) stage. Doc said CPAP *might* (not likely) help my PLMD, but he put me on it because I was feeling puke tired and having instances of gasping for air in the morning. I'm not on SSRI's but I have been told that can be a trigger also.

It's too soon to tell but after 28 days, I haven't had an attack that I was aware of (my longest stint prior to cpap was 2 days in a row without a PLMD arousal and/or twitching and "growing pains" in my shins). I'm wondering if mine might have been partially aggravated by apnea.

My point is, PLMD stinks. You get no restful sleep... it can be triggered by a lot of things, and everyone's triggers are different. Hopefully you and your doc can start eliminating things, or preferably find something that manages your symptoms. I hope that you get closer to a resolution.

[Wulfman...]

Den, I do not know how to change the settings on my machine. Am I allowed to do that, will my doctor get annoyed? Ive taken 2 screenshots of the last couple of nights.

Here's a link to download the clinical/setup guide to your machine.
Yes, you ARE allowed to do that. It's YOUR machine and YOUR therapy. Even if your doctor were to get annoyed, remind him/her whose therapy it is and you're trying to tweak your settings for optimal benefits and sleep quality.

https://sleep.tnet.com/home/files/resme ... -guide.pdf

In any case, you're having almost no events with your settings. But, I think if I were you, I'd try straight pressure at 8 or 9.
In view of your lack of events.......Flow Limitations and a few snores being what's driving your pressure changes.......you now need to find out if straight pressure will help your sleep quality. Our breathing can change as we go into deep and REM sleep stages. If Flow Limitations or Snores are detected, it will drive up the pressure.......which MAY bump the user out of that sleep stage and into a lighter one.

Some people are not disturbed by pressure changes and some definitely are. Everybody's different and need to explore the best settings for themselves.


Den

.

[Masta]

PLMD stinks. I'm sorry you're going through that.

I'm no doc, but mine has told me that PLMD is caused by neuro but can be triggered by a lot of things. We investigated low iron levels (nope, mine are high for a woman). My antihistamines guaranteed an especially active night... I went the length of doing immunotherapy so I wasn't quite as dependent on antihistamines. Adding exercise was a chicken and egg problem (balancing the right amount of exercise but being too exhausted to do the requirement). One thing that did consistently help me was magnesium supplements but my digestive tract hated it... My body was fighting sleep however it could. I was put on a lot of different Parkinson's medications, but in the end the doctor said basically I went through enough torture so we gave up... Lunesta was my work around. It didn't fix my problem, it just allowed me to get a little bit of sleep between the irritating part and the actual kicking myself awake (and making my dog yipe) stage. Doc said CPAP *might* (not likely) help my PLMD, but he put me on it because I was feeling puke tired and having instances of gasping for air in the morning. I'm not on SSRI's but I have been told that can be a trigger also.

It's too soon to tell but after 28 days, I haven't had an attack that I was aware of (my longest stint prior to cpap was 2 days in a row without a PLMD arousal and/or twitching and "growing pains" in my shins). I'm wondering if mine might have been partially aggravated by apnea.

My point is, PLMD stinks. You get no restful sleep... it can be triggered by a lot of things, and everyone's triggers are different. Hopefully you and your doc can start eliminating things, or preferably find something that manages your symptoms. I hope that you get closer to a resolution.

Yoshi, I have checked my (TIBC) iron and ferritin. I have had a a huge list of different blood tests done, for other reasons (Hypothyroid, low progesterone, low adrenal function, cbc, cmp, liver function tests, all hormones checked, checked for lupus and a bunch of other tests) plus asthma, spinal stenosis and degenerative disc disease and facet joint problems). I do take magnesium and Vit D when I remember to take it right before I go to bed. it helps a little. my legs ache all the time, I have to move them when im sitting down or resting on my bed. hubby tells me I kick in bed allot. Im pretty much bed ridden due to my spine problems. so cant walk much. I have allergies too, i havent bothered with doing the injections to become immune to my allergies, I dont take antihistamines. 10mgs of prozac is a small dose. Ive had this leg issue for yrs, way before I started on Prozac. My doctor isnt the type of doctor to rule out problems, all he says is there is nothing that can be done to help me with my lack of rem sleep and PLMD. he doesnt offer suggestions or to rule out anything. he is dumbfounded, which makes me feel like he is really a pulmonologist that does sleep tests on the side, he isnt an experienced sleep doctor. and yes... having PLMD stinks!! I am on opioid medication and muscle relaxers, I take them sparingly, only when I cant handle my spine pain, or for spine ablations. I do notice I have more Central Apneas when im on both meds.

[kteague]

You situation is difficult in the respect that some meds you need might be problematic for you. I won't delve into the meds issue as I don't have any answers. Here's some things to sort through before your sleep study. A titration study is not what you need. You need a study using your CPAP at its usual settings the entire night for them to see what is happening with you when at home. I really think a titration study is a waste of time, unless you've never had one. I really don't want this to be a rant about your doctor. I will say I consider it irresponsible to tell someone with sleep apnea to stop using their treatment when you know their issues are likely unrelated to that treatment. Especially when any sleep doctor should know the classification of your degree of severity lacks full diagnostic info needed to make a conclusive determination. Had you slept better that night in quantity, sleep stages and positions that are conducive to a reliable determination, you might find have found your sleep apnea is actually farther along the severity scale. Also, any sleep doctor should know that in the presence of PLMD, sleep apnea may not be fully appreciated. Unfortunately, your doctor is not a rarity in this arena.

Another thing to consider before your study is whether you want results with or without the pain meds. I'd be interested in the input of others here. I think I'd want to know if the meds cause significant centrals and if the treatment that works without the meds is still adequate when taking them. Good luck with all this. We've talked before in PM's. Sorry to hear things aren't better yet.

It may be your CPAP therapy has room for improvement. Others have spoken to that. I suggest you optimize and continue with CPAP treatment and revisit things when you have the info from your new sleep study and can reassess the possible roles of your PLMD and medications. Do consider that if your sleep is resolved your need for meds may change.

[Jay Aitchsee]

Hi Masta,

I don't have too much to offer. I, too, suffer from PLMD and know it can be really tough to control.

I do suggest you look at the timing and amount of Vitamin D you are taking. In my experience, excess Vitamin D can be disturbing. Many are now recommending Vitamin D3 serum levels between 50 and 80 ng/ml. You may want to monitor your levels to see where you are with supplementation. Another consideration could be the timing of the dose, since one normally gets Vitamin D through exposure to sunlight, it would seem logical to take a supplement during the day (morning) rather than at night. Now, I have no idea whether the timing makes a difference or not, but there is some anecdotal evidence suggesting that it does. In any case, it wouldn't hurt to try it.

I would be suspicious of the role anti-depressants and other meds might play in your lack of REM/poor sleep. Maybe you could try a reduction in dosage or different drugs? Here's a link to some of the side effects antidepressants might have http://www.psychiatrictimes.com/sleep-d ... ants-sleep

In my case, I have been through most, if not all, of the commonly prescribed tests and drugs to treat PLMD without success. So, what I have done is concentrate on "good" sleep by getting my SDB under control with CPAP, monitoring and supplementing Vitamins D3 and B12, exercising daily, eating a more wholesome diet by eliminating most processed foods, and rigidly adhering to the best sleep hygiene possible. Although I still have PLMD, I now get much better sleep, feeling more rested with much less fatigue than when I started this journey some 8 years ago.

J

Edit: Oops, I see Pugsy already referenced the same article regarding antidepressants. That's OK, it just kind of underscores the role meds might play. I also agree with Den that you should try a constant pressure (CPAP mode). It looks like something around 9 should do nicely. Many people are disturbed by the pressure changes of APAP.

[Masta]

Den, I do not know how to change the settings on my machine. Am I allowed to do that, will my doctor get annoyed? Ive taken 2 screenshots of the last couple of nights.

Here's a link to download the clinical/setup guide to your machine.
Yes, you ARE allowed to do that. It's YOUR machine and YOUR therapy. Even if your doctor were to get annoyed, remind him/her whose therapy it is and you're trying to tweak your settings for optimal benefits and sleep quality.

https://sleep.tnet.com/home/files/resme ... -guide.pdf

In any case, you're having almost no events with your settings. But, I think if I were you, I'd try straight pressure at 8 or 9.
In view of your lack of events.......Flow Limitations and a few snores being what's driving your pressure changes.......you now need to find out if straight pressure will help your sleep quality. Our breathing can change as we go into deep and REM sleep stages. If Flow Limitations or Snores are detected, it will drive up the pressure.......which MAY bump the user out of that sleep stage and into a lighter one.

Some people are not disturbed by pressure changes and some definitely are. Everybody's different and need to explore the best settings for themselves.


Den

.

Den, I will definitely change my setting to 9 once im done with my sleep study.

You situation is difficult in the respect that some meds you need might be problematic for you. I won't delve into the meds issue as I don't have any answers. Here's some things to sort through before your sleep study. A titration study is not what you need. You need a study using your CPAP at its usual settings the entire night for them to see what is happening with you when at home. I really think a titration study is a waste of time, unless you've never had one. I really don't want this to be a rant about your doctor. I will say I consider it irresponsible to tell someone with sleep apnea to stop using their treatment when you know their issues are likely unrelated to that treatment. Especially when any sleep doctor should know the classification of your degree of severity lacks full diagnostic info needed to make a conclusive determination. Had you slept better that night in quantity, sleep stages and positions that are conducive to a reliable determination, you might find have found your sleep apnea is actually farther along the severity scale. Also, any sleep doctor should know that in the presence of PLMD, sleep apnea may not be fully appreciated. Unfortunately, your doctor is not a rarity in this arena.

Another thing to consider before your study is whether you want results with or without the pain meds. I'd be interested in the input of others here. I think I'd want to know if the meds cause significant centrals and if the treatment that works without the meds is still adequate when taking them. Good luck with all this. We've talked before in PM's. Sorry to hear things aren't better yet.

It may be your CPAP therapy has room for improvement. Others have spoken to that. I suggest you optimize and continue with CPAP treatment and revisit things when you have the info from your new sleep study and can reassess the possible roles of your PLMD and medications. Do consider that if your sleep is resolved your need for meds may change.

kteague,
I agree with you about my sleep doctor being irresponsible when it comes to him telling me to stop cpap therapy. and also him not knowing the full extent of my sleep apnea due the the fact i didnt sleep well during the overnight test.
I do keep a record of when i take my pain medications, (muscle relaxers and opioids). I dont have any central apneas when i dont take any pain meds, and I always have central and abstuctive apneas on those medications. one of my screenshots was a night I took meds. I rarely take pain meds, so im going to do the sleep test not on any pain meds. When the time comes for me to be on pain meds fulltime, I'll let my sleep doctor know about the central and obstuctive sleep apneas.

Hi Masta,

I don't have too much to offer. I, too, suffer from PLMD and know it can be really tough to control.

I do suggest you look at the timing and amount of Vitamin D you are taking. In my experience, excess Vitamin D can be disturbing. Many are now recommending Vitamin D3 serum levels between 50 and 80 ng/ml. You may want to monitor your levels to see where you are with supplementation. Another consideration could be the timing of the dose, since one normally gets Vitamin D through exposure to sunlight, it would seem logical to take a supplement during the day (morning) rather than at night. Now, I have no idea whether the timing makes a difference or not, but there is some anecdotal evidence suggesting that it does. In any case, it wouldn't hurt to try it.

I would be suspicious of the role anti-depressants and other meds might play in your lack of REM/poor sleep. Maybe you could try a reduction in dosage or different drugs? Here's a link to some of the side effects antidepressants might have http://www.psychiatrictimes.com/sleep-d ... ants-sleep

In my case, I have been through most, if not all, of the commonly prescribed tests and drugs to treat PLMD without success. So, what I have done is concentrate on "good" sleep by getting my SDB under control with CPAP, monitoring and supplementing Vitamins D3 and B12, exercising daily, eating a more wholesome diet by eliminating most processed foods, and rigidly adhering to the best sleep hygiene possible. Although I still have PLMD, I now get much better sleep, feeling more rested with much less fatigue than when I started this journey some 8 years ago.

J

Edit: Oops, I see Pugsy already referenced the same article regarding antidepressants. That's OK, it just kind of underscores the role meds might play. I also agree with Den that you should try a constant pressure (CPAP mode). It looks like something around 9 should do nicely. Many people are disturbed by the pressure changes of APAP.

Jay,
I take my Vitamin D3 5000IU at night right before bed with a combination pill of Magnesium 500mg, Calcium 500mg and Potassium 99mg . I do get my Vit D levels checked regularly, and I do stay within range. Im housebound/bedridden due to pain, so I do not get much sunlight (living in USA). Im on one of the smallest doses of Prozac 10mg, I dont think there is a smaller dose in capsule form available.
I dont know what you meant by "So, what I have done is concentrate on "good" sleep by getting my SDB under control with CPAP". what is SBD?

[49er]

""Jay,
I take my Vitamin D3 5000IU at night right before bed with a combination pill of Magnesium 500mg, Calcium 500mg and Potassium 99mg . I do get my Vit D levels checked regularly, and I do stay within range. Im housebound/bedridden due to pain, so I do not get much sunlight (living in USA). Im on one of the smallest doses of Prozac 10mg, I dont think there is a smaller dose in capsule form available.
I dont know what you meant by "So, what I have done is concentrate on "good" sleep by getting my SDB under control with CPAP". what is SBD?""

Prozac comes in 5mg. Check with your local pharmacist as I don't think this is well known.

SBD stands for sleep breathing disorder.

49er