Sleep Arousals - how to measure and improve?

Hi Folks,

I wonder if anyone has spent time determining and improving on their general sleep arousal events? (number of wake-ups throughout the night not related to apneas)

I've been fortunate enough to get my AHI index down to almost 0.0 over the last five nights - virtually no apneas. (Actually one night was 0.27 before pressure adjustments) Before, it was absolutely terrible. It's time to move on and look at other factors to improve sleep.


WAKE-UPS:

Over the last five nights I have seen my wake-ups go from about 5-6 times, mostly for bathroom breaks, down to only one per night. Last night I slept 9 hours and got up after 7 hours for the bathroom. However, I can "remember" waking up to toss and turn a few times. These are the events I'd like to work on and don't show up in the data. My mask stayed on the whole night and is not a factor, unless the occassional leaks are bothering me. My ASV PEAK pressure can hit nearly 20 cm/H20 at times.

I'm interested in others' ideas and experiences for improving their so-called "sleep arousal index," if there is such a thing.

I have looked at the SleepyHead data for clues of arousals, but feel the short wake-ups to roll over are buried in the data. I thought about using a camera, but wondered if anyone has worked out a more systematic method to work on this problem? There are some very clever people on this BB and I don't want to reinvent the wheel....

Thanks.

Tom


Here is some background info/data of my situation:
viewtopic/t81612/ASV-RESULTS-and-Charts--Success.html

Morning Tom
Love your avatar..we used to have an English Springer Spaniel, best pet we ever had.
Regarding your arousals, getting up to pee only once in the night is fabulous, and your ahi index is wonderful too. i would not worry about your tossing and turning just yet.....your brain and body are being re-trained to do everything, and that takes time. Your brain is used to telling your body to move, once it get used to all the changes (for the good) then I'm sure things will settle down nicely. This therapy takes patience and persistance, but in the end its a god send when you are sleeping like a log and getting up refreshed and alert to your upcoming day.
Good luck...as I said you are doing wonderfully
Cheers
Nan

Hi Tom, welcome. See the links in my signature for ideas about using a Zeo and/or Camera to monitor sleep.

You don't say if you feel rested even though you are experiencing wake-ups. If you do feel rested, I wouldn't worry too much about the wake-ups. Certainly some are normal. Search Deltadave's posts for arousal index information.

Jay

You've made a lot of progress, good for you !!

I have pondered arousals as well, I may come up with some sort of metric for my use. I have an accelerometer that tells me when I move, it's velcro'ed to my head (LOL!). Here's a link to my blog about the accelerometer:
http://wiredapneic.blogspot.com/2012/06 ... meter.html


Here's what I was doing last night...



The lines are X, Y, and Z positions of my head and as the lines shift up and down I'm moving. In the beginning I was pretty tranquil and later I was moving quite a lot. The tranquil periods are correlated with deep sleep, a good thing, but we need just so much. This leads me to some thoughts about sleep arousals... first, one would think minimizing them would be good, but also one must ponder that, in moderation, they are important to health, arousing slightly, shifting your body to aid the lymph system, organs, etc. and to find an improved breathing position. We don't want to fully "sleep like a rock" literally and some arousal and movement is probably natural and good for us. So the question I ponder is how much is optimal? I'm guessing "everything in moderation" rules here too.

Here's a posting by Deltadave
viewtopic.php?f=1&t=81294&p=739631#p739631

Jay Aitchsee wrote:Here's a posting by Deltadave
viewtopic.php?f=1&t=81294&p=739631#p739631

I'm trying to figure out the units of that chart. That is total events per hour? Naawwww... it must be event count in a night's sleep? (Calling Delta Dave, Calling Delta Dave, ... Over)

The Sheikh,

As someone who had a long, drawn out War on Insomnia, I have spent a great deal of time in figuring out how to improve the overall quality of my sleep, and part of that has been dealing with multiple significant wakes after sleep onset. And while reducing the number of wakes/arousal has played a role in conquering my insomnia, a far more important part of my CBT-I focused on teaching myself how to NOT over think about my wakes and how to PREVENT myself from overreacting to normal, insignificant awakenings/arousals.

Even folks with high quality sleep will have a few arousals and awakenings during the night. (Waking a few times during the night to assess one's safety is an evolutionary advantage.) But the total number of these arousals/awakenings is relatively few in number AND they are relatively short. Studies have shown that non-isomniacs do wake up periodically during the night (often at the end of a REM cycle), but after quickly verifying there's no need to be awake, they snuggle back down into the covers and fall back asleep almost immediately. And in the morning, these non-insomniacs typically remember none of these short wakes/arousals because a wake typically has to last at least five minutes before a non-insomniac stands a chance of remembering it.

I point this out because it can be counterproductive to focus large amounts of time and energy attempting to eliminate every wake and arousal. The immediate goal should be to get to where a short wake or two (or three) during the night does not cause you to stress out about waking up. Rather than worrying about the wake, the focus should be teaching your body how to get back to sleep so quickly that these last few (normal) non-respiratory wakes/arousals are not remembered in the morning.

In particular, you write:

I have looked at the SleepyHead data for clues of arousals, but feel the short wake-ups to roll over are buried in the data. I thought about using a camera, but wondered if anyone has worked out a more systematic method to work on this problem? There are some very clever people on this BB and I don't want to reinvent the wheel....

"Short wakes to roll over" are NOT a problem with your overall sleep architecture. And hence there's no need to try to find or eliminate them. Most people benefit from changing position a few times during the night: It minimizes stiff necks and sore backs caused by sleeping in an awkward position for too long. Moreover, trying to identify and eliminate these short "normal" wakes may inadvertently get you so focused on trying to "remember" all the wakes that you wind up increasing their lengths to at least 5 minutes, and that in turn can create a problem with sleep maintenance insomnia.


Now you also describe your situation as:

WAKE-UPS:

Over the last five nights I have seen my wake-ups go from about 5-6 times, mostly for bathroom breaks, down to only one per night. Last night I slept 9 hours and got up after 7 hours for the bathroom.

Sounds like nocturnia was a symptom of your sleep apnea. Could be that last bathroom break will also disappear all by itself --- if you don't get worried about the fact that you are not sleeping.

However, I can "remember" waking up to toss and turn a few times. These are the events I'd like to work on and don't show up in the data.

Ok---"remembering" tossing and turning is no fun. And it can take a lot out of you the next day. But rather than focusing on the vague sense of tossing and turning as evidence of "wakes/arousals that must be eliminated", you should focus your time and energy on trying to figure out what was creating the discomfort that lead to the restlessness and work on minimizing that.

Let's look at some potential causes of the restlessness. That will give you some ideas on where to start working to reduce the restlessness, which in turn will give you more continuous sleep.

Leaks
You write:

My mask stayed on the whole night and is not a factor, unless the occasional leaks are bothering me.

You mention, but seem to dismiss, leaks as a very real possibility for what triggered your restlessness. So what's your leak line look like? Was last night's leak line similar to the one you posted to that other thread? That one looks like this:



So what's the take on this leak line? You're using a ResMed S9 ASV. So that leak line includes only the unintentional leaks. Now, it's true that your leaks on this night are mostly below the RedLine at 24 L/min that ResMed uses to define a large leak. But your leaks on this night were still both long enough and large enough to make leaks into a very plausible source for the restlessness. So look at last night's leak line. Are there some bumps on it? The bumps do NOT need to be big enough to affect your therapy---even a small leak in the wrong place can cause you to get restless. Can you show us your leak line for last night?

Necessary pressure swings from the ASV
You write:

My ASV PEAK pressure can hit nearly 20 cm/H20 at times.

The ASV PEAK pressure shooting up to 20 cn H2O might also be triggering some restlessness. It's going to just take some time (as in several weeks to a few months) for your brain and body to get fully accustomed to all the sensory stuff coming from having a mask on your face, being tethered by a six foot hose, and having your machine blast your airway with 20cm H2O because the machine doesn't like the way you are breathing (or perhaps more accurately, not breathing.) So if this is the source of the restlessness, the problem may resolve itself in a few weeks---if you don't start obsessing about the fact that you are not yet sleeping as well as you would like to.

Other possible causes of the restlessness
All sorts of (external) things can cause us to be restless during the night. Some of them we can work on; others mat be beyond our control. Common causes of restlessness include pain, side effects from drugs, bad sleep hygiene, disruptive sensory stimuli (dogs barking, traffic noise, bed partner tossing and turning, feeling too hot, feeling too cold, too much light), allergies, cold and flu symptoms, weather (some folks are sensitive to changes in the barometric pressure), an uncomfortable bed, and worry.

So read through that list and add anything that you know has caused you to be restless in the past to the list. For the ones you can do something about, work on solving the potential trigger problem. For the ones that are out of your control, work on controlling your nighttime response to finding yourself awake or restless during the night. Learn to chill out about the wake and allow yourself the pleasure of going back to sleep. And if sleep doesn't come, get out of bed, go to the bathroom (even if you don't "need to go") and allow yourself to relax and get sleepy before going back to bed.

Confusions about definition of arousal:
-normal functioning arousals: when finishing a section of delta wave sleep and moving to stage 1, for example.
-microarousals (<3 seconds) counted?
-roll over and your EEG spikes; is that arousal?

I wake up 4-6 times a night that I remember. ~1 1/2 hours after I get up, I feel like lying down on the floor and doing nothing. My scored arousals are ~10/hr, but something is still wrong.

Peter Hauri says normal sleepers in their 20s have 5-8 arousals an hour.

MaxDarkside, Barry Krakow said that one should be able to place a pair of socks at the foot of the bed and have them still be there in the morning.

MaxDarkside wrote:

Jay Aitchsee wrote:Here's a posting by Deltadave
viewtopic.php?f=1&t=81294&p=739631#p739631

I'm trying to figure out the units of that chart. That is total events per hour? Naawwww... it must be event count in a night's sleep? (Calling Delta Dave, Calling Delta Dave, ... Over)

My guess is that the vertical scale is indeed the total number of arousals for the night and that someone made a really bad mathematical boo-boo in labeling the graph. I bet the vertical axis should have been labeled as (arousal index) * TST instead of (arousal index)/TST.

robysue wrote:

MaxDarkside wrote:

Jay Aitchsee wrote:Here's a posting by Deltadave
viewtopic.php?f=1&t=81294&p=739631#p739631

I'm trying to figure out the units of that chart. That is total events per hour? Naawwww... it must be event count in a night's sleep? (Calling Delta Dave, Calling Delta Dave, ... Over)

My guess is that the vertical scale is indeed the total number of arousals for the night and that someone made a really bad mathematical boo-boo in labeling the graph. I bet the vertical axis should have been labeled as (arousal index) * TST instead of (arousal index)/TST.

see Deltadave's reference: http://www.journalsleep.org/articles/210404.pdf

Summary: EEG arousals were quantified in 40 nocturnal polysomnographic recordings belonging to four age groups
(teenagers: 10 to19 years; young adults: 20 to 39 years; middle-aged: 40 to 59 years; elderly: ≥ 60 years). Ten subjects (five
males and five females) participated in each group. The subjects were healthy and sound sleepers. All sleep recordings were
preceded by an adaptation night which aimed at excluding the presence of sleep-related disorders. The recordings were carried
out in a partially soundproof recording chamber and in a standard laboratory setting. Arousal indices (AI), defined as the
number of arousals per hour of sleep, were calculated for total sleep time (AI/TST) and for all the sleep stages. AI/TST
increased linearly with age (r=0.852; p<0.00001): teenagers (13.8 ), young adults (14.7), middle-aged (17.8 ), elderly (27.1).
An age-related positive linear correlation was found also for the arousal indices referred to NREM sleep (r=0.811; p<0.00001)
and to stages 1 and 2 (r=0.712; p<0.00001), while in stages 3 and 4 and in REM sleep, arousal indices showed stable values
across the ages. Overall, arousals lasted 14.9±2.3 seconds, with arousal duration stable across the ages (range of
means: 13.3-16.6 seconds) and no relevant differences between NREM sleep (14.6±2.5 seconds) and REM sleep (16.2±5
seconds). The paper discusses the impact of age on arousals, the similarities between arousals and the phases d’activation
transitoire, and the consideration that arousals are physiological components of sleep.

Jay Aitchsee wrote:see Deltadave's reference: http://www.journalsleep.org/articles/210404.pdf

AI: arousal index (number of arousals per hour of sleep) referred to: TST (total sleep time)

OK, so that chart is arousals per hour, averaged over the total sleep time. The "/" is not a mathematical division, but a reference to the period. Those are EEG arousals, which would be much more than what you and I would sense.

Thanks.

Wow... excellent infomation! More than I hoped for....

Comments:

Nan - Yes, Springers are such great dogs. This is my third over 35 years.

Jay - Very interesting on your Zeo experiences. I read over your complete thread in detail. That may be what I am looking for. It will give a good general trend to better evaluate what's happening. Right now I am happy with the SleepyHead data, except for leaks, and looking to take the next step to see if I can do even better.

I use SleepyHead - cuz it's simple - ResMed seems like a DOS program to me - tough to use. I see ZEO data upload-capable in S/H - this will work out OK, yes? Think I will pick one up. Thanks for the info.

Max: I read over your complete thread a week ago about building up the positional device. Quite cool. I have an elec engr background, but might have a tough time of interfacing the software and data as you did. Not sure what an alternative would be other than a time-stamped camera. Someone mentioned using a WIFI 1 sec frame digital camera for the job. Yes, it's too bad ZEO does not have a position indicator. It wud be a natural.


RobySue - Your post was exceptional and I must read it over a few more times. Yes, the leaks may be causing some of the arousal problems. I woke up the other night with air coming out of my mouth as I was talking... it definately scared the dog... (nasal mask - also have a FF mask) I have been somewhat lazy about the nasal mask, keeping it looser for comfort since the AHI was down to 0.0 and it felt OK to have a constant leak as long as the breathing was perfect. But the honeymoon is over now that I see it could be causing the unwanted arousals.

Interesting on the need to wake up and check our own safety. This sounds logical.

How do I feel? I haven't felt better in years! In just one week on the ASV the fog has lifted, my chest and arm pain are gone and I don't have panic attacks when dozing off, due to the LONG centrals I had when falling asleep. This ASV has changed my life. (The CPAP made it worse as you can see in the other thread charts)

I won't post last night's SH charts cuz they look almost exactly like the one here. The leaks are the same and the AHI is 0.0. But I will definately focus on getting the leaks way down... thanks for the heads up reasons.

The other potential problems affecting sleep you listed.. I have most everything covered, except for perhaps brief worry about upcoming events.. nothing much. My health is now almost perfect, weight and blood pressure OK. This cental apnea WAS the main culprit wearing me down despite being healthy and now it's under control.

I have some more comments and questions, but will break for now. The ZEO and mask leaks suggestions are take-home pay and I will start looking into them.

Thanks again everyone.

More suggestions are welcome.

Tom

A report on arousals:

Arousal is believed to be needed for upper airway opening in obstructive hypopneas–apneas, without compelling evidence to support this notion. The association may be incidental. I studied the temporal relation between arousal and opening and impact of arousal on flow response at opening in 82 patients (apnea–hypopnea index, 46 ± 35/hour). Obstructive apneas–hypopneas were induced by dial-down of continuous positive airway pressure. Obstructions and hypopneas occurred in 44 and 56% of dial-downs, respectively. When arousal occurred (83% of dial-downs), the temporal relation between arousal and opening was inconsistent between and within patients. Frequency of opening without or before arousal increased with milder obstructions (p < 10−9) and with delta power of EEG (p < 10−6). Time of opening was unaffected by whether arousal occurred before or after opening (18.0 ± 9.8 vs. 18.1 ± 10.5 seconds). Flow response was already excessive when opening occurred without or before arousal (180 ± 148% of initial flow decline) and was considerably higher when arousal occurred (267 ± 154%, p < 10−10). Flow undershoot after first ventilatory response was greater if arousal occurred (p < 0.01). It is concluded that arousals are incidental events that occur when thresholds for arousal and for arousal-independent opening are close. They are not needed to initiate opening or to obtain adequate flow and they likely increase the severity of the disorder by promoting greater ventilatory instability.

Source: http://ajrccm.atsjournals.org/content/1 ... l.pdf+html


As to any problems with leakes in the following graphs, b/c the leaks exceed the 24 L/Min levels for only short times, I don't think that a Resmed machine should be affected much by it. IMO, ResScan graphs show more reliable results of Resmed machines data. If leaks are much over 24 L/Min then ResScan classify events as Unknown and show them in graphs as such.



Example of Unknown events in ResScan (in yellow), b/c of Leaks, while on CPAP:




Resmed VPAP ASV Graphs in ResScan:

(From a poster in 2010, see how the Leak graph creeps above the red line, even if the Pressure stays low)

Jay Aitchsee wrote:Hi Tom, welcome. See the links in my signature for ideas about using a Zeo and/or Camera to monitor sleep.
You don't say if you feel rested even though you are experiencing wake-ups. If you do feel rested, I wouldn't worry too much about the wake-ups. Certainly some are normal. Search Deltadave's posts for arousal index information.

Jay

Jay,

I read more about your home sleepy study office. Pretty slick. Gonna order the ZEO Bedside Sleep Mgr for $149.

Question: How do you wear that Zeo sensor headband at the same time as a FF mask or nasal mask? Both of my masks have a forehead brace that would interfere with the Zeo headband...?

Tom

The Sheikh wrote: RobySue - Your post was exceptional and I must read it over a few more times. Yes, the leaks may be causing some of the arousal problems. I woke up the other night with air coming out of my mouth as I was talking... it definately scared the dog... (nasal mask - also have a FF mask) I have been somewhat lazy about the nasal mask, keeping it looser for comfort since the AHI was down to 0.0 and it felt OK to have a constant leak as long as the breathing was perfect. But the honeymoon is over now that I see it could be causing the unwanted arousals.

Work on fixing the leaks rather than trying to sort out how many arousals and awakenings you are having.

How do I feel? I haven't felt better in years! In just one week on the ASV the fog has lifted, my chest and arm pain are gone and I don't have panic attacks when dozing off, due to the LONG centrals I had when falling asleep. This ASV has changed my life. (The CPAP made it worse as you can see in the other thread charts)

All the more reason to NOT obsess about identifying and eliminating those few wakes. Why not enjoy how you are currently feeling and just give your body and mind a bit more time to just learn how to ignore (i.e. not remember) those few small short wakes that are not related to leaks?