Where do you go from here?

[greenguru]

I have analysed and studied and just not sure where to go. I have gotten AHI under control:

AHIApnea / Hypopnea Index 2.32
HypopneaHypopnea 0.11
ObstructiveObstructive Apnea 0.63
Clear AirwayClear Airway Apnea 1.58
RERAResp. Effort Related Arousal 0.11
VSnore2Vibratory Snore #2 2.53
PB/CSRPeriodic Breathing 0.78%

but I still wake up 10 - 13 times a night (per ZEO) ?????

Anyone have any ideas? Thanks!

[BlackSpinner]

Why don't post a chart for a night and indicate the times the zeo says you are awake?

[robysue]

I have analysed and studied and just not sure where to go. I have gotten AHI under control:

AHIApnea / Hypopnea Index 2.32
HypopneaHypopnea 0.11
ObstructiveObstructive Apnea 0.63
Clear AirwayClear Airway Apnea 1.58
RERAResp. Effort Related Arousal 0.11
VSnore2Vibratory Snore #2 2.53
PB/CSRPeriodic Breathing 0.78%

but I still wake up 10 - 13 times a night (per ZEO) ?????

Anyone have any ideas? Thanks!

And how many times do you say you wake up each night?

It's important to realize that the Zeo can frequently mis score bot REM and LIGHT sleep as WAKE. The zeo makers point this out on their web pages if you read carefully.

[123.Shawn T.W.]

And ... How do you FEEL?

[greenguru]

BackSpinner: Sorry I had to open up acct on Photo bucket and work out the mac logistics. Graph from good night below. 13 wake ups.

123.Shawn TW: I feel like I have woke up several times in the middle of the night. If I sleep for a long enough duration, The extra sleep counteracts being awake an hour or more. I am not able to sleep in every day.

Robysue: As I said 10-13 times. Good nights are 9 never much less. I understand the ZEO disclaimer but my eyes are open and I see the time.

Thanks everyone.

http://i1254.photobucket.com/albums/hh6 ... 4511PM.jpg


http://i1254.photobucket.com/albums/hh6 ... 2239PM.jpg

[greenguru]

Sorry wrong link. First time.

[robysue]

Robysue: As I said 10-13 times. Good nights are 9 never much less. I understand the ZEO disclaimer but my eyes are open and I see the time.

So I'm trying to get this straight: You remember a whole lot of wakes even before you look at the Zeo data?

So you've got some real problems with sleep maintenance insomnia. And it is clear the OSA is not (directly) responsible since the AHI is now nice and low.

Questions for you to think about:

1) Is this pattern of lots of wakes new in the since of starting at around the same time you started CPAP? Or did you had this kind of a problem with lots of wakes for a long time prior to your OSA diagnosis?

2) Have you considered talking to your sleep doc about the sleep maintenance insomnia as its own problem instead of only in the context of OSA and CPAP adjustment? If not, that might be a good next step.

3) What kinds of things have you tried? How effective (or ineffective) were they?

4) How's your sleep hygiene? Almost every insomniac has things they need to work on.

5) What goes through your head when you first wake up in the middle of the night and look at the clock? Do you start trying to figure out how long you might have slept since the last wake? Do you start focusing on how little time there is before morning? Do you find that you spend a lot of that wake time simply worrying about things?

Finally a suggestion: Get a copy of Sound Sleep, Sound Mind by Dr. Krakow and work your way through it with an open mind. He has a tremendous amount of stuff to say about what kinds of things insomniacs do that make matters worse and what kinds of things you can try in order to replace the insomnia-feeding behaviors with behaviors that encourage you to sleep soundly.

[greenguru]

Robysue interesting stuff.
Yes I remember a lot wakes before looking at ZEO. In fact I bought ZEO to correlate the wakes with the osa data.

Yes I was experiencing the wakes before diagnosis of Apnea. Diagnosis was result of detection during surgery on toe. I did not have the bad falling asleep and headaches.

I was hoping the OSA was the cause. These are great AHI numbers vs. my sleep study numbers. CPAP really got the numbers low after 157 days. My sleep doc is kinda learning as he goes. I set the final numbers on my pressure. I told him what I did and why and he did not dispute. Besides I own the machine. I think he learned something from me. I learned from reading all your posts. I must admit since O2 levels are good now I have energy but if I could lick the waking up, I would have more.

I was a person who was on call for 30+ yrs. Traditional hours was not normal for me. I would get calls in the middle of the night, and sometimes multiple times. So this probably contributed.

I have looked at the hygiene things and will continue too. I will check out the book. Thanks for the feed back.

[old64mb]

One of the nice but tricky things about the Zeo is that it provides evidence of problems, but doesn't necessarily provide a diagnosis.

To me, that's the case here. Something is waking you up multiple times in a night for fairly long periods of time, but it's unclear as to what exactly it is. It may be insomnia, but what concerns me is maintenance insomnia doesn't explain what shows up on the sleep chart.

The normal sleep cycle is pretty clear: you go into light sleep first, then back to deep, then up to REM, then start all over again, with deep being prevalent early in the evening and REM later in the evening.

One of the biggest problems with apnea is that you end up nuking both deep and REM sleep precisely because apnea forces you to start the sleep cycle all over multiple times per night. That is, it's somewhat hard to get either of the above if you keep being pushed back to the start line and begin at light sleep 70 or 100 times a night.

What's very odd about your sleep cycle from the one night you've shown is that you're bouncing in and out of deep sleep to being fully awake back to deep sleep, and that's not a normal sleep pattern whatsoever. Some of this may be the Zeo's tendency to smooth data over a bit when it defines the categories, but that much deep sleep and REM despite all the fragmentation is just really odd.

I have no problems believing there's some insomnia going on here based on your description of looking at the clock in the middle of the night and being on call for so many years, but my suggestion would be to go back to the sleep doc and point out the multiple arousals despite no sign of OSA causing them. You definitely have some work to do on the sleep discipline side - I'd move the clock out of the bedroom, for instance - but it wouldn't surprise me if the doc wants you back for another sleep study to see if there's something they missed (or has come to the fore after treatment of the OSA) like PLMD.

[greenguru]

I agree, I think you are correct. I keep lowering AHI, O2 levels up but not feeling fantastic. Maybe my expectations are to high. ZEO was for looking into that problem. I am about to set up movie camera on myself to see if I can find correlation between times and awakenings. As for the usual stuff. I am semi-retired. When I wake up I am not fretting about the problems of today or tomorrow. I fall asleep right away. There is no noise. I don't watch TV in bedroom. I am not following blackberry...etc.etc. I did that in the past. I was a Sr. Operating Systems Engineer for 30+ yrs. The largest mainframe computers in the world. I spent my career trying figuring out cause and effect with computer problems and performance. I am trying to figure out this problem. Last night I achieved my lowest AHI ........ 1, wow! But still 9 awakenings. I took .75 mg of melatonin. My initial thoughts are the sleep improved. The awakenings were not as long. We will see over time. i am pondering St. Johns Wort to increase serotonin levels. This may improve my staying asleep. Graphs from last night below. Any thoughts are appreciated. Thanks.

[Pugsy]

Cpap machines are designed to fix one specific sleep issue.....prevent apnea events.
If your sleep apnea events weren't totally responsible for your poor sleep or fragmented sleep then we can't expect cpap to fix bad sleep. We would like for it to but it just doesn't. Had that happen to me. Got great AHI numbers but still poor sleep due to multiple awakenings...in my case due to pain which of course is unrelated to sleep apnea. Had to find something to help deal with the pain and/or help sleep a little deeper so that the pain didn't cause me to wake up 20 times a night.

You will need to try to figure out what is causing the awakenings and/or find something to help sleep a little deeper and lessen the wake ups. This is harder work than using a cpap machine. So you get to go through the common things first that affect sleep like meds (do any of them cause insomnia or mess with sleep....my main pain med does cause insomnia), pain, general health issues, bed comfort, etc. Lots of detective work to try to figure out what is going on.

[old64mb]

As Pugsy said, you've got some detective work upcoming. This where a visit to your sleep doc with the data - both the low AHI and the repeated awakenings - probably would help.

[Jay Aitchsee]

Greenguru, I don't have much to offer that hasn't already been said. But I share your situation. I've had my apnea well under control for quite a while, but restorative sleep alludes me. My sleep is fragmented and I get little deep sleep as reported by my PSG's and Zeo.
I would suggest you get a full blood work up to check for any deficiencies, in particular Vitamin D3, B12, Ferritin, etc. You need to rule things out. Be cautious of Meds, many, even those prescribed for sleep, will produce abnormal sleep architecture.
I think Pugsy mentioned it, but sometimes sacrificing a little AHI for comfort by lowering your pressure will provide more comfort and a better night's sleep.
Alcohol can be a real problem. I'm just sayin'. I am an abstaining alcoholic. Hard core from my teens til around 50. Classic overachiever. I mention this because there is a study that found that abstaining alcoholics had fragmented sleep years after they quit drinking and something in your posts reminded me of myself - no offense
Check my signature for some home sleep lab ideas. Best of luck to you.

Jay

[greenguru]

Pugsey - Thanks. I still am no sure if pain is prob.....rotator cuff repair 6 mo. ago. at the beginning of this CPAP adventure. Not on any meds right now.
But if your roll over on the shoulder wrong.....It will wake me.

Old64mg - Thanks. Started reading about sleep architecture.

Jay -No offense taken. Thanks. Nicotine was my addiction. 7 yrs. quit. My blood work is ok just had it checked.

AHI - .34 last night. Pressures at 10, If i lower it the AHI goes up. Maybe the camera is the way to go.

Thanks all.

[robysue]

Pugsey - Thanks. I still am no sure if pain is prob.....rotator cuff repair 6 mo. ago. at the beginning of this CPAP adventure. Not on any meds right now.
But if your roll over on the shoulder wrong.....It will wake me.

Pain could be part of the problem.

I was a person who was on call for 30+ yrs. Traditional hours was not normal for me. I would get calls in the middle of the night, and sometimes multiple times. So this probably contributed.

Undoubtedly this learned sleep behavior is part of the ongoing problem with multiple wakes. It's been "normal" for 30+ years to not be able to expect a night without external reasons for waking. So your body and mind have learned to expect and cope with multiple wakes each night. Unlearning this sleep pattern will take time.

When I wake up I am not fretting about the problems of today or tomorrow. I fall asleep right away. There is no noise. I don't watch TV in bedroom. I am not following blackberry...etc.etc. I did that in the past.

So there have been problems with sleep hygiene in the past, but you've made some changes. How long has it been since you gave up the Blackberry and the tv? And while you say you don't worry when you wake up, you have admitted in other posts to looking at the clock when you wake up. You might want to turn the clock around and intentionally NOT try to remember the time of each and every wake. The very act of trying to remember when the wakes occur happens to be a significant source of food for routine sleep maintenance insomnia.

If you feel absolutely compelled to track when the WAKEs happen, you can get a reliable record of them by briefly turning your CPAP machine off and then back on when you wake in the middle of the night. This can also act as a reality check for the Zeo data.

AHI - .34 last night. Pressures at 10, If i lower it the AHI goes up.

How high does it go up if you make a very modest reduction of 0.5 to 1cm? If a modest decrease allows you to sleep with fewer arousals and your AHI goes from the 0.0-1.0 range to the 2.0-2.5 range, you may be better off allowing a few events to sneak through for less fragmented sleep.

Maybe the camera is the way to go.

Before going this far, I think you need to think carefully about what you intend to do with all data you are already gathering. And what you would do with whatever you might learn from analyzing hours of video data from each night's sleep with a camera pointed at your bed.

In my humble opinion, instead of adding hours of video data to add to your current data set, I think you need to start looking more critically at what you are trying to accomplish over all with all this data you are gathering each night. In other words, what do you hope to accomplish if/when you manage to reduce the number of night time wakes, improve your Zeo data, and keep the AHI <1.0 every night?

As SleepingUgly suggested to me way back in April 2011, what you need to do is to set some meaningful and measurable outcome variables. I mean I know that the overall goal is "feel and function better in the daytime"---but how can you quantify this? What factors can you measure (even if the measurement is mostly subjective) that might indicate real progress towards feeling and functioning better on a daily basis.

Once you know your outcome variables and how you plan on measuring them, you will have a clearer idea of what you are trying to accomplish. And once you know what you are trying to accomplish, you'll be in a position to do something with all the input data you are currently gathering because you'll then be able to see which of the multiple factors affecting your sleep seem to be most strongly correlated to improving your specific outcome variables. And that in turn may help you focus on which things you try to improve the quality of your sleep are really make a difference and which are less important.

And note that the variables you've been talking about in this thread---the AHI, the number of nighttime wakes, and the Zeo sleep stage data---are all input variables to your over all goal of feeling better. That doesn't mean that you shouldn't be trying minimize the number of wakes or trying to keep the AHI low or improving the sleep architecture, but it does mean you need to look at the "cost" of solving these problems in terms of optimizing your chosen output variables.

And so you also need to carefully track what each change you make does to both your outcome variables and the input variable that you are trying to optimize. And you need to give each change some time to make a real difference in whatever you hope it might influence. And that means actually documenting what happens to those output variables as carefully and as completely as documenting what happens to the input variables.

For example, you write:

Last night I achieved my lowest AHI ........ 1, wow! But still 9 awakenings. I took .75 mg of melatonin. My initial thoughts are the sleep improved. The awakenings were not as long. We will see over time. i am pondering St. Johns Wort to increase serotonin levels. This may improve my staying asleep.

Before you add St.John' Wart, give the current dose of melatonin a chance to demonstrate what it will do both for whether the subjective quality of the sleep is improved AND to determine whether there is any change in how well you function throughout the daytime. Give the melatonin a week or two as the only drug/supplement you are taking in an effort to improve your sleep for at least a week or so.

Likewise, give any changes to your sleep hygiene a week or two before declaring them a failure or only a partial success.

And, as I said before---it is important to document what's happening to your outcome variables as well as those input variables called "number of wakes" and "sleep architecture". A simple journal in a spreadsheet might suffice once you've decided how to measure your chosen output variables.