Help please: Sleep disturbances, clomazepam and SAD

[cnew]

I've been using APAP for a month and a half now. When I first started out, I was having some pretty good nights of AHI<5 and feeling good in the morning. Then, as my treatment progressed (and I have been 100% compliant), I started being bothered by early morning disturbances, leaks, feeling less rested, more crabby, etc.

I had my follow-up at the sleep clinic yesterday, and the doc seemed to think I was doing pretty good. (I have a question about how carefully he looked at my data, but we'll put that aside for the moment.) When I mentioned the early morning disturbances, he gave me a prescription for clomazepam sent me down to the DME to talk about possible mask leak issues. The DME pretty much told me I was doing well to be getting more than 4 hours of sleep, and I should quit my complaining. Citing Medicare rules, they said I wasn't eligible to try another mask yet, and I had to pitch a fit in order to get them to exchange the useless Sullivan chin strap they had very reluctantly given me when I first got my equipment for something that wouldn't slide off my head. I was not a happy camper and went back up to my doctor's office and told them the folks downstairs at the DME didn't give a flying "f" about helping me with my leak issues. When I started crying at the front desk in front of a waiting room full of people, they quickly ushered me into an office where I spilled my guts to a sympathetic nurse.

So last night, I took .25 mg of clonazepam, put on my new PR Premium chinstrap, my nasal pillow mask and turned out the light hoping to sleep past my usual 3:30 wake-up time. Instead, I woke up at 2:30.

Which brings me to the subject of Seasonal Affective Disorder (SAD). Several years ago, I was diagnosed with SAD and prescribed light therapy for it. At the time, I was suffering from the same sort of mood problems and interrupted sleep that I am experiencing now, and the morning light therapy helped. So I am wondering, because it is now mid-October, if my sleep disturbance issues are possibly being caused by my body's response to the diminishing photoperiod. With this hypothesis in mind, I started light therapy this morning, but the therapy will take a few days to kick in, if this is indeed the problem.

Would appreciate thoughts on this. I will attach a screen capture for last night in case anyone would like to comment on that.



I'm in a rather dark place at the moment, and need all the help I can get. Thank you!

[avi123]

How well are you managing with the light therapy for the SAD ? Is there no sun at your place? If yes, do you stay outdoors long enough?
Move south, if you can. I was born in a sub tropical country but after moving to Boston I felt shi-tty during the fall and winter. Later , I was saved by moving to Calif. and later to here. Looking at the light box did NOT help me.

http://www.mayoclinic.com/health/depres ... expertblog

[Pugsy]

Sleep fragmentation for any reason will certainly mess with how a person feels.

Robysue is one of our forum members who has the best input for staying asleep problems and she also uses the light therapy. Hopefully she will see this post and offer her ideas. She usually will especially with a topic like sleep disturbances.

In the meantime she has a blog with some thoughts that might help you.
You can read it here. A lot pertains to cpap induced problems but the basics also work for other problems.
http://adventures-in-hosehead-land.blog ... er_19.html

[cnew]

I just started light therapy this morning. It has been effective in the past. I don't take melatonin and don't fancy adding another drug to the cocktail I already take.

It's not a matter of sunny days vs cloudy days or how long one is outside. We've been having sunny days here, and I do get outside. The problem with SAD (as opposed to the milder mood changes people experience when the sun isn't out) has to do with the length of the photoperiod (i.e. dawn to dusk) which is getting shorter everywhere north of the equator, I believe. Certainly everywhere in the U.S. Therefore, moving south is not really a solution to this problem.

[cnew]

Robysue is one of our forum members who has the best input for staying asleep problems and she also uses the light therapy. Hopefully she will see this post and offer her ideas. She usually will especially with a topic like sleep disturbances.

Thank you, Pugsy, I was hoping you would look at my graph and tell me if you see anything of interest or concern.

[jamiswolf]

Hi Cnew,
It isn't uncommon to have a really good start and then have problems arise. Just remember that this is a long term effort and little set-backs can be expected.

I like the crying in the lobby maneuver. I haven't tried that one, but I may use it in the future. But being that I'm a 6'2" 250 pound man, they'd probably just send in the guys in the white suits to haul me away.

"There coming to take me away Hey HEY"

Far as SAD is concerned, when I lived up north...including Minnesota, North Dakota and Iowa, I always managed SAD by having a little grow room in my spare bedroom. A 400 watt Metal Halide light is way better then the wimpy flourescent therapy lights. I'd spend time with my plants tending them, drinking my morning coffee there and reading there. Heat humidity and light light light. Then at harvest time you have some veggies to eat, flowers to smell, ganja to smoke or whatever.

Your numbers aren't horrible. Room for improvement certainly. You just need to hang in there and deal with problems one at a time. Seriously, things could be way worse and I know that's a meaningless platitude for you right now so I won't bother with examples.

Only you can dig yourself out of this hole your in.

Good luck and best wishes,
Jamis

[avi123]

Sorry, i need to leave, got an appointment with marquee de SAD

[Pugsy]

Thank you, Pugsy, I was hoping you would look at my graph and tell me if you see anything of interest or concern.

Sorry forgot.
Your minimum is 5? Max 10.5? I cannot see the pressure line on this image.. too faint I guess.
From the AHI obstructive component (we don't treat the CA) AI of 3.87 and HI 1.76 gives us 5.63
and that I feel could be improved on. Would like to see this less than 5. I suspect the minimum pressure is not quite sufficient. Your overall average pressure is around 8. If this were my report I would increase the minimum to 7 cm. I see no need to increase the maximum unless you are seeing the max being reached often for prolonged periods of time.

The minimum of 5 may just be a little too low. These machines don't respond to event precursors with immediate large pressure increases. They go up in stages and if pressure is too low starting out it can't reach optimal pressure in time to effectively prevent the events. The events come and go before the machine can reach the pressure needed to prevent the obstructive events. So I would suggest give it a bit of a head start with a small increase in minimum.

We don't try to treat the CA events as the machine won't respond to clear airway events.. it isn't supposed to.

If you think your OSA is worse on your back and you sleep on your back more you could try staying on your side to see if that helps. Though your pressure needs are low and a small increase in the minimum might just take care of it and you can sleep anyway you want. You have lots of wiggle room there. Me? I would let the machine do its job and sleep however I wanted and you might not even be horribly worse on your back anyway. I am not. I am worse in REM sleep. So if this were my report I would increase minimum to 6....see how it does with those obstructive events (don't count the CAs) and then maybe 7 cm minimum.

Have I confused you? Let me know and I will try to reword.
You might feel better with the obstructive component 3 or less. In your mind you have to subtract the CA component because pressure doesn't treat it. If your fragmented sleep is reduced..you may see a reduction in CA because some of those might be sleep onset or sleep transition events.

[jules]

clomazepam is highly addictive

[cnew]

Your minimum is 5? Max 10.5? I cannot see the pressure line on this image.. too faint I guess.

I don't know why the pressure and leak lines are so faint. I will have to look into that. My pressure settings are 5/15, and the pressure line is fairly level around 8 or 9 for most of the night. Last nights leak graph was the best yet, with virtually no leaks detected, thanks, I think to my new chin strap.

From the AHI obstructive component (we don't treat the CA) AI of 3.87 and HI 1.76 gives us 5.63
and that I feel could be improved on.

Thank you. So do I!

Would like to see this less than 5. I suspect the minimum pressure is not quite sufficient. Your overall average pressure is around 8. If this were my report I would increase the minimum to 7 cm. I see no need to increase the maximum unless you are seeing the max being reached often for prolonged periods of time.

The minimum of 5 may just be a little too low. These machines don't respond to event precursors with immediate large pressure increases. They go up in stages and if pressure is too low starting out it can't reach optimal pressure in time to effectively prevent the events. The events come and go before the machine can reach the pressure needed to prevent the obstructive events. So I would suggest give it a bit of a head start with a small increase in minimum.

We don't try to treat the CA events as the machine won't respond to clear airway events.. it isn't supposed to.

If you think your OSA is worse on your back and you sleep on your back more you could try staying on your side to see if that helps. Though your pressure needs are low and a small increase in the minimum might just take care of it and you can sleep anyway you want. You have lots of wiggle room there. Me? I would let the machine do its job and sleep however I wanted and you might not even be horribly worse on your back anyway. I am not. I am worse in REM sleep. So if this were my report I would increase minimum to 6....see how it does with those obstructive events (don't count the CAs) and then maybe 7 cm minimum.

Have I confused you? Let me know and I will try to reword.
You might feel better with the obstructive component 3 or less. In your mind you have to subtract the CA component because pressure doesn't treat it. If your fragmented sleep is reduced..you may see a reduction in CA because some of those might be sleep onset or sleep transition events.

No, you haven't confused me. I'm sincerely grateful for any and all suggestions. You seem to know a LOT, and you are very good at explaining your thinking.

I am much more comfortable on my side, but I guess I can't be trusted to stay put once I go to sleep, and if I do end up on my back, the OSA is definitely worse. In fact, that's how the doctor ordered that I sleep during the sleep study, so that we would get the worst possible outcome. And that was AHI=25 and RDI=44 and no REM sleep whatsoever. It was not a good night!

I might try experimenting, as you suggested, with a slightly higher minimum pressure. Another alternative approach that was suggested by the respiratory therapist was to switch from APAP to CPAP at 8 cm which was the magic pressure from the titration part of the sleep study. I may try that at some point, too.

Thank you again to taking the trouble to comment on my situation.

[cnew]

Hi Cnew,
It isn't uncommon to have a really good start and then have problems arise. Just remember that this is a long term effort anlittle set-backs can be expected.

I know. I'm in it for the long haul, but I so wanted it to be an overnight miracle. Damn!

I like the crying in the lobby maneuver. I haven't tried that one, but I may use it in the future. But being that I'm a 6'2" 250 pound man, they'd probably just send in the guys in the white suits to haul me away.

"There coming to take me away Hey HEY"

You like that, huh? But seriously, if you knew me, you would know how out of character it is for me to show that much emotion. I'm normally a pretty stoic Scandinavian type, if you know what I mean. It tells me that my mood is impaired, and I guess that's the reason I shared it.

Far as SAD is concerned, when I lived up north...including Minnesota, North Dakota and Iowa, I always managed SAD by having a little grow room in my spare bedroom. A 400 watt Metal Halide light is way better then the wimpy flourescent therapy lights. I'd spend time with my plants tending them, drinking my morning coffee there and reading there. Heat humidity and light light light. Then at harvest time you have some veggies to eat, flowers to smell, ganja to smoke or whatever.

Your grow rooom sounds very theraputic. I live in Minnesota.

Your numbers aren't horrible. Room for improvement certainly. You just need to hang in there and deal with problems one at a time. Seriously, things could be way worse and I know that's a meaningless platitude for you right now so I won't bother with examples.

Only you can dig yourself out of this hole your in.

Good luck and best wishes,
Jamis

I know things could be a lot worse. I will hang in there and deal with the problems in turn. Thank you for your kind words and good wishes.

[cnew]

There hardly are any event seen in the chart. But, a SAD leads to depression. And a depression is one of the underlying medical conditions to screw up data for any CPAP and even nullify its treatment (if needed). IMO, your best bet would be to put the damn CPAP aside and treat your SAD and depression first.

Is there another event besides the one at 22.20?

There are many events, but they are very pale and hard to see in the image I posted. Sorry. I don't know why the image quality is so poor.

[cnew]

clomazepam is highly addictive

I don't like the idea of being on another drug anyway, and to tell the truth, the doc was kind of on the fence about it, too. So, I think I may hold off on it, especially since it didn't seem to help me last night. In fact, I woke up earlier and in a worse mood!

[Pugsy]

Another alternative approach that was suggested by the respiratory therapist was to switch from APAP to CPAP at 8 cm which was the magic pressure from the titration part of the sleep study. I may try that at some point, too.

This would also be a good experiment. There are usually several ways to obtain optimal pressure. You could also use a tight APAP range to mimic cpap but still have a little variable available for any possible stubborn events. Like 7 min and 9 max. Or 8 min and 10 max.

I use APAP 10 minimum and 20 max. I do this because sometimes I need 18 cm. I am not particularly worse in regards to events on my back but I am documented worse in REM. Most of the time my pressure stays around 11 to 12 and my overall average (over many months) is 12.4. But sometimes I get some super strong events, likely in REM so I let the machine do what it is designed for. Works for me and I never notice the pressure changes until I see a report.

Some people find that pressure changes in APAP do disrupt their sleep somewhat and those people will do better with a tight range in APAP or even using straight CPAP.

I am currently experimenting with a BiPap set to straight BiLevel. Something completely new. Not because I need it particularly for high pressure as the 10 cm isn't that high or bothersome for me. After some more time using it (only been a week) I will post my observations and what lead me to try this machine. So far it has been wonderful.

In your situation I would hope that perhaps if we can get your obstructive component down a bit (in case the events are disturbing your sleep) and also have you test cpap to see if the pressure changes are waking you up...maybe get you so that you don't need the clomazepam.
I do understand fragmented sleep. In my case not related to OSA but related to pain..so I have to take something to help with pain and also help me sleep through the pain so it doesn't wake me every time I move.

[M.D.Hosehead]

clomazepam is highly addictive

I don't like the idea of being on another drug anyway, and to tell the truth, the doc was kind of on the fence about it, too. So, I think I may hold off on it, especially since it didn't seem to help me last night. In fact, I woke up earlier and in a worse mood!

The decision whether to use pharmacologic sleep aids is highly individual. That said, clonazepam isn't the best choice, IMO. For trouble initiating sleep, The z-drugs

http://en.wikipedia.org/wiki/Z_drugs

are more effective and safer. For trouble maintaining sleep, OTC Benedryl, low dose trazadone or doxepin, or extended release z-drugs are more effective and safer than clonazepam, again JMO.