Sleep apnea and insomnia-quality vs. quantity

When I told my Doctor last fall that I was still dealing with insomnia (after many years), he recommended I get a sleep test. I did, and was diagnosed with moderate SA (untreated, 28). I really hoped that the CPAP would help my insomnia but three and a half months in, it hasn't.

Maybe my expectations were too high. I know CPAP is good for my SA and I plan to continue using it (fortunately I haven't had many problems adjusting to it), but it's discouraging that I'm still only getting 3-4 hours of sleep per night. I've been told that at least the "quality" of sleep is better, but frankly I don't feel it. I'm still tired. BTW. I don't have problems falling asleep, I have problems staying asleep and waking up too early. And yes, I do practice good sleep hygiene, by avoiding caffeine, no TV in bed, keeping the bedroom dark, no mobile screens in bed, etc. While I do have sleeping pills (both short term and long term), I'm really resistant to using them too often. I also should note that in the first couple weeks of using CPAP, I was often able to get back to sleep after waking up, so I was hoping that my insomnia would eventually go away (or at least lessen).

I've heard that "the jury is still out" on the direct correlation between SA and insomnia. Has anyone found that CPAP helped with their insomnia at all? Would love to hear a success story or two.

While sleep apnea is a common cause for insomnia it isn't the only cause...sometimes we simply don't know the cause.
Sleep onset insomnia is where we have difficulty falling asleep. Sleep maintenance insomnia is where we have problems staying asleep and either wake up and can't go back to sleep or wake up a bunch of time but can get back to sleep fairly easily.

Effective cpap therapy will take care of insomnia when sleep apnea is the only cause of the insomnia but it doesn't work so great if there are other causes unrelated to sleep apnea.

Prior to cpap I had significant sleep maintenance insomnia due to OSA events particularly in REM sleep causing me to wake up multiple times and I am not talking 3 to 5 times..I am talking double digit times. Never got much REM because every time I would hit REM sleep the OSA came on with a vengeance and I would either wake up or have a low level arousal that would kick me out of REM.

So effective cpap therapy did help the insomnia in some regards...not as many wake ups but I have another health issue that also affected sleep quality and that was significant arthritic pain. I still had too many wake ups when I was hurting and it hurt to stay in one position and it hurt to move so I was really caught between a rock and a hard place. To make matters worse my pain pill that works really good during the day caused insomnia and would "wire" me up. Slept good for about 3 hours and then I would wake up wide awake with no chance of going back to sleep so I had to work with my doctor to find something that would help with the pain and not wire me up.

People who don't even have OSA have various forms of insomnia. Dealing with the OSA insomnia is really quite easy but it gets a lot more difficult when the insomnia is caused by something we can't put a finger on.
Lots of detective work is involved and sometimes we still can't find an answer.

My usual thoughts when insomnia is a problem...
1....First make sure that your OSA appears to be well treated at least on paper and this is where the software comes into the picture. AHI itself doesn't always tell the whole story.
2....Look at current meds to see if any of them are known to maybe affect sleep in any way.
3....Look at other health conditions as a potential factor...like in my case pain
4....Look at bed comfort in general.

For me it took a lot of experimenting and trial and error to get my sleep maintenance insomnia under some semblance of control. It still isn't perfect but it's a lot better than it was when I first started therapy.
For me to not remember waking up during the night..hey that's a major earth shattering miracle. I count it a good night if I remember 3 to 5 wake ups that I can go right back to sleep.
Took probably 2 years to come up with various improvements to help...new bed for back comfort...various combinations of meds that help sleep but don't wire me up and don't leave me a zombie the next day and still help with the pain levels. It's a battle I really never win totally but now the good nights far outweigh the bad nights.

novatom wrote: I've heard that "the jury is still out" on the direct correlation between SA and insomnia. Has anyone found that CPAP helped with their insomnia at all? Would love to hear a success story or two.

I wish I could give you a clear success story. But I can't.

I can tell you that it is possible to manage both the insomnia and the OSA at the same time. And once both are under control, you do start to feel better in the daytime.

In my case, the insomnia became overwhelming after starting PAP therapy. So be very happy that you've not had any serious problems adjusting to your CPAP.

As far as managing the insomnia goes: Here are some things that I have found help me. Your mileage may vary.

1) Realistic expectations about what a good night's sleep for me actually is. In my case, it is unreasonable to expect that I will ever sleep soundly for a solid 8 hour stretch without waking up. It just ain't gonna happen. But if I can keep the wakes down to a reasonable number AND get back to sleep within 5 minutes or so of each wake AND get a total of 6 hours of sleep or so, then I feel pretty decent the next day. So my goal is to increase the number of nights where my sleep is good enough to allow me to feel pretty decent the next day.

2) Short latency to sleep at the beginning of the night. You say this is not a problem for you. That's great! When I started CPAP, latency to sleep became a huge problem for me because I was so uncomfortable with the mask on the whole time I was trying to get to sleep. It took a lot of hard CBT-Insomnia to teach myself how to fall asleep within 10 minutes or so of going to bed since that's about as long as I can comfortably lie in bed with the mask on.

3) Establishing regular bedtimes and wake up times and using them seven days a week. This is the one part of good sleep hygiene that still remains difficult for me. I have a lot of data from both my old sleep logs and my machine's data that clearly indicate that my insomnia is much better controlled when I go to bed and get up at the same time every day. For me, getting up at the same time (regardless of how well or how poorly I slept) is a critical part of managing the insomnia. But it still remains difficult for me to force myself to do it at times.

4) Not lying in bed while wide awake for long periods of time. It's not the easiest thing for me to do, but I do try to get out of bed and go into a different room when I find myself unable to get back to sleep in a timely fashion. I go back to bed only after I start feeling sleepy again. I've also found that if I set my bedtime and wake up times so that only a little longer than what I typically sleep on my best nights, that seems to encourage my body to try to stay asleep better. What I mean by this: On a good night I typically get 6 to 6.5 hours of sleep. So I try to keep my bedtime about 6.5 to 7 hours before my wake up time.

5) Judicious use of prescription sleeping pills. I was very, very reluctant to take anything to help me sleep for a very long time. I even managed to get my CPAP-induced insomnia under control without much medication, but it required some very hard CBT-Insomnia. And through the years, I've found it harder to maintain the same kind of strict discipline when it comes to my sleep hygiene. Eventually my current sleep doctor persuaded me that perhaps sleeping pills could help me get a bit more sound sleep on a more regular basis. Technically the current script says for me to take a sleeping pill every day, but the sleep doc knows that I'm not comfortable with that. We've worked out several compromises that allow me to take the pills at a frequency that I am not overly concerned about. Some of my sleeping pill rules are:

• If I have a really bad night, I'll take a sleeping pill the next night even if I think I'll have no problems sleeping the next night.
• If I absolutely must go to bed earlier than my regular bedtime of 1:30, I'll take a sleeping pill. (The usual reason I have to go to bed earlier than I want is an early morning meeting that forces me to get up well before I usually wake up on my own.)
• If I start having trouble maintaining my bedtime---i.e. I find that I haven't been in bed before 2:00AM for 3 or 4 days in a row, I'll take sleeping pills at my 1:30 bedtime for 3-4 days in a row to see if I can start making myself get sleepy by between 1:30 and 2:00 again.

robysue wrote: 1) Realistic expectations about what a good night's sleep for me actually is. In my case, it is unreasonable to expect that I will ever sleep soundly for a solid 8 hour stretch without waking up. It just ain't gonna happen. But if I can keep the wakes down to a reasonable number AND get back to sleep within 5 minutes or so of each wake AND get a total of 6 hours of sleep or so, then I feel pretty decent the next day. So my goal is to increase the number of nights where my sleep is good enough to allow me to feel pretty decent the next day.

Forgot to add this:

A reasonable number of wakes for me typically means that I'm only waking up after every full sleep cycle. When I get 6 hours of sleep, I'm hoping for no more than 3-4 wakes during the night. And I'm hoping that there's at least 80-100 minutes between most of those wakes.

I want to expand on a point Pugsy made about medications causing sleep problems. In my long experience with sleep issues I have found out the hard way that both prescription and OTC medications can really mess-up my sleep. If you are taking any medication of any kind you may want to stop the OTCs one at a time for a few days and see if anything changes. If medically possible, do the same with any prescription medications.

Below is a link to Dr. Mercola's website where he discusses 33 things to do to optimize your sleeping environment. Light in the bedroom will absolutely destroy sleep, any light with the possible exception of red or deep orange light. Blue light is the worst by far. Some even recommend wearing blue filtering glasses a couple hours before bedtime to simulate the production of melatonin (I do this and it does help). Junk any device in your bedroom that produces either full spectrum light or blue light, which seems to be very common for alarm clocks and nightlights. As Dr. Mercola says, if you can see your hand in front of your face, it is to light in your bedroom.

Another sleep killer is room temperature. Keep it in the 60s if possible, if not, get a water cooled mattress pad. We have one in our bed and I keep my side set at 60. That sounds cold, but it really is not and will help.

Good luck, I know how hard the battle is.

http://articles.mercola.com/sites/artic ... sleep.aspx

Pugsy wrote:
''Prior to cpap I had significant sleep maintenance insomnia due to OSA events particularly in REM sleep causing me to wake up multiple times and I am not talking 3 to 5 times..I am talking double digit times. Never got much REM because every time I would hit REM sleep the OSA came on with a vengeance and I would either wake up or have a low level arousal that would kick me out of REM."

Pugsy,

I thought that having sleep apnea meant you never reached level 3-4 of sleep cycle and never , ever , REM sleep? I have severe sa, and my sleep lab test showed no
level 3, 4 or REM sleep.Can you clarify please.

I am a newbie ( one year on cpap) and it has truly been life changing- and thanks to this wonderful message board.

Slats wrote:I thought that having sleep apnea meant you never reached level 3-4 of sleep cycle and never , ever , REM sleep? I have severe sa, and my sleep lab test showed no
level 3, 4 or REM sleep.Can you clarify please.

Not to my knowledge does having sleep apnea totally prevent all people from going into the deeper sleep stages.
I think it all depends on the person and when the apnea events happen to wake them up and how the body responds. What might bounce you out of sleep might not bounce me out.
I got all the sleep stages during my diagnostic sleep study but I couldn't stay in REM where my OSA was worse and I kept waking up. It made for a difficult titration sleep study because I needed a lot more pressure in REM and at the sleep lab I barely got any REM to work with.

It's very possible that you didn't get to those later sleep stages for any number of reasons but it isn't an absolute given that sleep apnea totally prevents those deeper sleep stages in all people. It's going to be like everything else with this sleep apnea/cpap stuff...comes with a big YMMV sticker.
The deeper stages can be reached but are likely abbreviated because of the apnea events.

My OSA is worse in REM sleep and not so bad in non REM sleep which is quite common so it wouldn't be unusual for me to experience all the sleep stages because I might not wake up or have an arousal pull me out of a sleep stage until I hit REM. Perhaps your OSA is/was simply a lot worse than mine was in the lighter sleep stages so you got pulled out of your sleep sooner than I did and that's why you never progressed to the deeper stages.

Thank you everyone for your suggestions and help. I was naive to think that CPAP would fix my (sleep maintenance) insomnia, I guess. The more I read about the subject, the more I believe that relationship between the two is not all that close and that probably my only hope for getting a handle on my insomnia is good old fashioned sleep hygiene. I guess that explains why I don't see people talking about insomnia much on this board. But I take comfort in knowing that I'm at least getting a handle on the SA.

I think of it this way: If it hadn't been for the insomnia, I never would have gone for a sleep test and the detrimental effects of SA would be slowly deteriorating my system. I've never (consciously) felt or displayed the classic signs of SA, such as waking up out of air or the desire to fall asleep during the day.

Maybe someday there will be a machine as a drug-free cure for insomnia, but it would probably involve some form of mind control. So much of it seems to be mental and not physical, at least I think that's what's causing mine.

It sounds like you're already looking at some of the baseline things people fighting insomnia have to look at. Are you on any meds or taking any supplements that could be contributing to your insomnia? Did your studies make any mention of limb movements? I personally wake up a lot at night, but I fall back asleep quickly and feel like I slept well in between, so I'm ok with it. The not falling back asleep would be a problem. I have a personal theory (nothing scientific) - the brain likes repetition, or habit. It tends to do what it's used to doing. I think sometimes when the broken sleep is so ingrained providing an environment conducive to sleep may not be enough. After ruling out potential causes, maybe you could consider giving your brain a bit of help to break the patterns and establish new sleep habits. Have you tried a very small dose of melatonin when you wake up and can't go back to sleep? Or some of the OTC rest aids? If the problem becomes prolonged, while this is not ideal and may extend your sleep problems, if there is a time when you could take a good long nap with your machine, it seems that would be preferable to forever going on so few hours sleep.

novatom wrote:Thank you everyone for your suggestions and help. I was naive to think that CPAP would fix my (sleep maintenance) insomnia, I guess.

It could be worse: At least the CPAP hasn't caused your insomnia to explode the way it did mine back when I first started.

The more I read about the subject, the more I believe that relationship between the two is not all that close and that probably my only hope for getting a handle on my insomnia is good old fashioned sleep hygiene. I guess that explains why I don't see people talking about insomnia much on this board. But I take comfort in knowing that I'm at least getting a handle on the SA.

OSA can cause insomnia in some folks, and then with CPAP the insomnia goes away.

But a whole lotta other things can also cause insomnia. And if your insomnia has roots in things other than just OSA, then CPAP isn't likely to do much to fix the insomnia. Good old fashioned sleep hygiene can do wonders for keeping insomnia under control. Right now, I'm back to working hard on reestablishing the bedtime/wake up times seven days a week. I really don't like getting up at 8:30 on Saturdays. But c'est la vie.

As for insomnia talk on this board: It seems like it comes in waves. We'll get a bunch of newbies all complaining that they can't sleep on PAP and couldn't sleep before PAP. Or that they could sleep fine before PAP, but now they are lying in bed for hours at a time not being able to sleep ..... And then once those people either get things under control or disappear or both, it can be months before other round of insomnia+PAP posts get started. But there are several of us old-timers who deal with insomnia problems on an on-going basis even though our PAP therapy is effective.

Maybe someday there will be a machine as a drug-free cure for insomnia, but it would probably involve some form of mind control. So much of it seems to be mental and not physical, at least I think that's what's causing mine.

Yes, there's a lot of mental stuff with insomnia, starting with plain old stress and age. Best of luck with bringing your insomnia monster under control.