apap, flow limitations, weight loss...

[BryanC]

The middle segment....it's obviously much more exciting than the first or last sleep segment. So something changed during that middle segment time frame and my first suspect would be supine sleeping became involved.

I've notice on occasion (can't say it for fact) but the more tired I am, the more my sleep apnea acts up, sometimes even waking me before I completely fall asleep (that's probably while I have sleep anxiety, because for years before I was diagnosed with sleep apnea, I used to stop breathing as I was falling asleep and wake back up)

If you normally see the first wake period about 90 minutes or so after sleep onset then you may be waking up during REM stage sleep for some reason.

I'm definitely remembering more of my dreams now, but I've woken several times at night for as long as I can remember. Most of the time they don't seem to be triggered by any event (though I suppose it could wake me up and I just kind of poss and turn till coming completely awake?)

I think that this is where Robysue could some in and discuss the insomnia issues. She does that so much better than me.
[/quote]

Robysye?!

How are you feeling in general?

Lousy, tired all the time, when I go on long car rides (I try to avoid driving as much as possible) it becomes very hard to keep myself awake (but for some unknown reason I do everything in my power to keep myself from falling asleep in a moving car. Or airplain.). Mentally my short term memory is horrible (I lost it in a car accident when I was 16, but with work it got much better, though now with as sleepy as I am, it's either acting up, or I'm just not paying attention.) And basically, I can't think about anything complex (which is basically what I've done all my life, I like complex things), now the most complex I'll get is a game on facebook.

How would you rate your sleep quality as it is now?

lowsy.

How many times do you wake during the night and not turn the machine off?

I think very few, because when I awake, my mouth is usually dry (ding ding ding! mouth breathing!) so I take a sip then try to go back to sleep.

Congratulations on your weight loss. If just looking at the first and last segments...you perhaps don't need that 8 cm minimum...maybe could go a bit lower but the middle segment is a bit worrisome as we don't know what caused that change.

Thank you, weight loss isn't really as hard as 'they' try to make it out to be, but this isn't the proper area to discuss that. (60+ pounds though )

dropped the minimum to 4, and it didn't go above 8, and mostly stayed around 8, now that was only a night oh, but, I set the minimum to 8 figuring if 8 is taking care of things, we'll leave it at that but then it climbed a little more when low was at 8.

(According to the chart, last night I stopped breathing from 47:30 to 50:00. is that possible?! Though the pressure only went up to 9, even though the max was set at 20, and there are lots of pressure pulses)



should I assume this means I was actually mouth breathing?

don't think it really matters what your maximum is set at because the machine doesn't seem to want to go any further than it does unless you are experiencing aerophagia issues.
Have you tried cpap mode or apap mode with tight range to see if that helps you sleep a bit better with less wake ups?
Some people are super sensitive to the least little pressure change and when that happens cpap mode or apap mode with a tight 1 cm range might work better.

[/quote]

Yeah, I've been wearing one of these things for 10+ years, so I was on CPAP for quite some time. I actually started when the machines didn't record anything, they just blew out a certain pressure, and that's what you went with. Then, after I started wearing one, thr things just took off and they're everywhere now!

[Pugsy]

I don't see any indication of mouth breathing particularly...at least enough for it to be a big enough leak to impact therapy.
Total Leak would need to be up around 80 to 90 L/min before I would worry about it as long as it wasn't waking me up.

That string of OAs. The machine doesn't try to blow through the obstruction with a big fast burst of pressure. It goes up in small stages like you see here. That's just the way it works. Sometimes the airway collapses anyway.
You had what I would call a nasty little cluster of events.

[robysue]

Bryan,

I'm going to split my responses.

First let's deal with an "easy" thing.

You show the following graph:

(According to the chart, last night I stopped breathing from 47:30 to 50:00. is that possible?! Though the pressure only went up to 9, even though the max was set at 20, and there are lots of pressure pulses)

That pattern is referred to by my DME as a "patient disconnect". I don't like the terminology at all since it seems to "blame the user" in my opinion, but that's what they call it and I don't have a better name for it. Loosely the CPAP has lost track of your breathing for some reason. (Think a "glitch" in the programming or Pugsy's aliens if you will.) At any rate the machine is (for whatever reason) having a tough time detecting your breathing pattern. That's why it's sending out all those PPs---it's trying to make sure there's a living breathing human being at the other end of the tube.

Sometimes these "patient disconnects" happen when the leak is in Large Leak territory; sometimes they happen when the leak data is higher than normal and the breathing is a bit shallower than normal for that particular patient. And sometimes I think it's Pusgy's aliens. Your leaks are NOT in Large Leak territory when the "patient disconnect" starts, but they are moderately high and they seem to be higher than in other parts of your data.

At any rate, I would NOT assume that you really had a 2 1/2 minute apnea here. I'd assume a glitch in the data due to aliens.

should I assume this means I was actually mouth breathing?

Maybe, maybe not. Unless you start to see a lot of this kind of "patient disconnect" stuff, I wouldn't get too worried about it.

[robysue]

Bryan,

Now I want to address the fragmented sleep/possible insomnia issues with you. I'm afraid this might take a couple of long posts, so bear with me. Also please read carefully and answer the questions that I ask. I've italicized the questions so hopefully they'll be easier to find.

First I'd like to synopsize what seems to be going on. Correct me if I make mistakes in summarizing what you've written in this thread.

First you write:

I've woken several times at night for as long as I can remember. Most of the time they don't seem to be triggered by any event (though I suppose it could wake me up and I just kind of poss and turn till coming completely awake?)

and

I have sleep anxiety, because for years before I was diagnosed with sleep apnea, I used to stop breathing as I was falling asleep and wake back up)

So you have a long history of fragmented sleep with multiple night time awakenings that seem to have no apparent cause. And you have some real sleep anxiety that has NOT abated with the use of CPAP.

Question: How does the sleep anxiety manifest itself? Do you get anxious before you go to bed and have trouble getting to sleep? Or does the sleep anxiety only become an issue if you start to feel like you are noticing apneas before you are fully asleep?


Second you write:

I still wake up (completely) 3 times a night, and generally only sleep 6 hours a night.

So as hard as it maybe for you to believe this, the actual number of awakenings (that you remember) is NOT actually excessively high. But your overall sleep time is only 6 hours, and for many people, that's not quite enough.

Question: How long is your "sleep window"? In other words, what time are you attempting to go to bed at night? And what time do you get up for the day?


Third you write:

as for going back to sleep, it varies, some nights it'll happen right away, some nights I lay there awake for hours, other times, I'm simply not 'tired' so I get for an hour or so then go back to bed.

So sometimes you get back to sleep without any problem (that's good), sometimes you just get up because you know you're not sleepy enough to get back to sleep in a timely fashion, and sometimes you "lay awake for hours". It's a bad habit (if you have an insomnia problem) to lay in bed "awake for hours" during your sleep window.

Question: How do you make the decision to lay in bed even afer it's become clear that you are NOT falling back asleep relatively quickly?

Question: What do you do when you first become aware that you are awake in the middle of the night? Do you look at the clock as soon as you first wake up? Do you immediately focus on the fact that you are AWAKE yet again and start worrying about why you are awake?

Fourth, you write:

generally I stop drinking caffeine around 3pm, and stop eating around 9 (when going to bed around 10)

So you are trying to limit caffeine after 3:00pm. And you try to not eat at least an hour before bedtime.

Question: How much caffeine do you consume before 3:00pm in an average day?

Question: When you do eat between 8:00pm and 9:00pm, what kinds of things do you eat?

Question: When you go to bed at 10:00pm, are you genuinely sleepy? Or are you just exhausted?

Question: What does the rest of your sleep hygiene look like?


Finally you write:

lately (per doctors orders) I take a sleeping pill (ambien) an hour before I go to bed, and one when I wake up at night (taking 2 when I go to sleep I only did once. Apparently that made me sleep walk, and I went back to bed and didn't put my mask on, so after the first 'wake' I have no record of anything.)

So prescription sleep medication is being tried with mixed success.

Question: How much ambien are you taking? Are you taking 1-2 5mg tablets? Or is the middle of the night dose a smaller dose?

Question: Are you taking ambien every night an hour before bedtime? Or are you taking only on some nights?

Question: Are you taking Ambien CR or just plain old Ambien? It makes a difference.

Question: When you do take the second dose after you first wake up in night, is that second dose effective at helping you get back to sleep? Does taking the second dose help prevent or minimize the number of additional wakes after that first wake?

Plain old Ambien is pretty good at helping bedtime (sleep onset) insomnia, but it's not particularly effective at helping sleep maintenance insomina. In other words, a lot of people who take Ambien still have problems with wakes during the second half of the night. For some people, Ambien may make those middle of the night wakes harder to remember, and that will make them feel better. (More on this in the next post.)

It also seems odd that your instructions are to take the Ambien an hour before going to bed. For most people, if Ambien is going to work (in the sense of helping you fall asleep), it helps within the first 15 minutes of taking it. Ambien also has a relatively short half life of only 2-3 hours: In other words, for most people, the body clears half the dose of Ambien about 2.5 hours after taking the Ambien. And as the level of Ambien in the body goes down, the effectiveness of the Ambien at both helping you fall asleep and helping you stay asleep goes down.

By taking the Ambien a full hour before you go to bed, it seems like you are both reducing the effeciveness of the drug for helping you get to sleep AND you are reducing the amount of Ambien in your body while you are asleep AND that makes he Ambien even less effective at preventing the night time wakes.

Observation: If I were you, I'd talk to the doc (at length) to double check the instructions on how to take the Ambien. I'd also ask the doc for information about why he wants you to take it an hour before going to bed when the usual guidelines are to take it just before you climb into bed.

[robysue]

BryanC,

Now for some information to put the fragmented sleep/insomnia issues in some perspective.

To paraphrase Sludge from his Muffy/NotMuffy days: CPAP/APAP doesn't fix bad sleep. CPAP/APAP fixes OSA and if there are any other causes of the bad sleep, the sleep's gonna stay bad even after the CPAP/APAP therapy is optimized. Because CPAP/APAP doesn't fix bad sleep.

And from what you've written, it seems as though there is something other than (untreated or under treated) OSA that is causing the bad sleep. Seems like you are dealing with some sleep maintenance insomnia issues (multiple wakes that you remember) and perhaps some sleep onset insomnia issues (sleep anxiety?)

If we look at the last FULL NIGHT of data you posted:

what jumps out from an insomnia point of view are the two long periods when the machine was not running: There's a 25 minute gap from (roughly) 0:15 to 0:40 and an even longer 70 minute gap from 3:05 to 4:15.

You've said that you will get out of bed when you wake up and can't get back to sleep. I'm assuming that's what happened for both these gaps: You turned the machine off and were AWAKE until you went back to bed and masked up and turned the machine back on.

As Pugsy points out: The timing of that first wake is about 2 hours after you went to bed, and it could easily be a normal post-REM awakening. (More on these later.) The second wake looks like it happened about 2.5 hours after you went back to bed. It's possible that this might still be a post-REM awake. Or it's possible that you were pretty restless for sometime before the wake. Any ideas on how restless you were after you went back to bed at 0:35? And did you take an Ambien at either of these wakes?

The machine was turned on at 22:05 (basically 10:00pm) and turned off at 5:34. Assuming that you got up at 5:34, that means that your "sleep window" was approximately 7.5 hours long. The therapy time is listed at 5:53 (almost six hours), which is consistent with the wake times: We know you were awake for at least 95 minutes in the middle of the night. That leaves you with no more than about 5:50 hours of sleep (at most) on this night, and probably less. But let's round it up to 6 hours of actual sleep in a 7.5 sleep window: That's a sleep efficiency of 6/7.5 = 0.80 = 80%, which is pretty lousy.

You might just feel better if you could get the sleep efficiency up to 90% (or at least 85%) even if you were not sleeping much longer than six hours: Being awake for long periods of time when you want to be asleep is itself exhausting and can make you feel miserable (both in terms of tiredness and sleepiness) the next day.

So you need to work on reducing the time you are awake. Of course you already know this. So how does one go about trying to reduce the time you're awake during your sleep window?

One critical trick is to reduce the length of each awakening rather than trying to eliminate all the awakenings. In other words, if you were to continue waking up roughly 3 times a night, but you were only awake 5-7 minutes at each wak, then the total wake after sleep time would be only 15-20 minutes all night long. And in that case, you'd have (roughly) 7.17 to 7.25 hours of sleep in your 7.5 sleep window. And if you were to get 7.2 hours of sleep, that would give you a sleep efficiency of 7.2/7.5 = 0.96 = 96% and you would probably feel much better than you do now, even though you still woe up 3 times during the night.

So how does one go about reducing the length of an individual wake in the middle of the night? That's a toughie. But one thing that may help is trying to change your behavior patterns that happen right after you notice that you are AWAKE in the middle of the night. Which brings us back to:

Question: When you first become aware of the fact that you are AWAKE what do you do? I mean when you are still in bed---what's the first thing you think about or the first thing you do? Do you immediately look at the clock? Do you start worrying about the fact that you are awake again? Do you expect or worry that you won't be able to quickly fall back asleep? Do you start trying to figure out why you are awake?

If those are the kinds of things that start going through your mind when you first become aware of the fact that you are awake, then you are likely making the wake last longer and you are making it harder to get back to sleep.

Here's something to keep in mind: Even people with perfectly normal sleep patterns (no OSA and no insomnia) typically wake up a few times each night---most often right at the end of a REM cycle. The thing is non-insomniacs respond very differently to the wake than insomniacs do: When non-insomniacs wake up, they typically determine that there's nothing external that needs their attention like a crying baby or some other night time emergency. And after quickly determining that there's no reason they need to be awake, they turn over, snuggle back into the covers, and go right back asleep. In the morning, they probably won't even remember the wake because the wake lasted less than 5 minutes. (In order to remember a wake in the morning, it typically needs to be at least 5 minutes long.)

Contrast that to what many insomniacs do when they find themselves awake: The first thing they do is think Crap, I'm awake again... And they typically look at the clock immediately after waking up. And after looking at the clock they start focusing on worrying about the time: How long have I slept since the last wake? How long is it before the alarm goes off? And they start worrying about why they woke up in the first place and whether they're going to get back to sleep or not. And all of that worrying tends to make the wake last longer AND makes it much harder to get back to sleep. And because it's harder to get back to sleep and the wake lasts longer, the wake is much more problematic than it should be with regards to sleep cycles and the overall quality of your sleep.

It takes time and effort to try to break that insomniac behavior cycle that occurs each time a typical insomniac wakes up: It's easy to tell someone Don't stress out about the wake; just turn over and assume that if nothing's obviously wrong, the wake is likely a normal post-REM wake and allow yourself to go back to sleep. But it is hard to not worry when you are used to worrying in the middle of the night. If you do any kind of mindful relaxation techniques or meditation during the daytime, adapting those techniques for when you wake up in the middle of the night can help. Some additional things that might help

• Turn the clock around so you can't see it when you first wake up. And try not to obsess about finding out the time when you do wake up at night.
• When you first become aware of the fact that you are awake, pay attention to your physical comfort rather than wondering or worrying about your (lack) of sleep. Does the pillow need fluffed or squashed? Covers need thrown off or pulled up? If there's an obvious comfort problem, fix it. And if there's nothing in particular that seems wrong, assume that there really is nothing wrong and give yourself permission to just turn over and (try to) go back to sleep. If you can't get back to sleep after a 15-20 minutes of trying, you can always get up later ...
• Try to not micro analyze the wakes, particularly during the night. Most likely there really is no particular reason why you are waking up, other than you're in the habit of waking up (and then worrying about the fact that you are awake).

NOTE: I'll be on the road tomorrow driving from Kalamazoo, MI through Chicago and onto St. Paul. So don't expect me to see any posts to this thread until very late tomorrow night.

[BryanC]

Question: How does the sleep anxiety manifest itself? Do you get anxious before you go to bed and have trouble getting to sleep? Or does the sleep anxiety only become an issue if you start to feel like you are noticing apneas before you are fully asleep?

Long before I was diagnosed with sleep apnea, as I would start to fall asleep, I'd stop breathing, and come back to fully awake trying to breath, and because of that, I just have always been 'afraid' to go to sleep (though I haven't had that problem since using the CPAP (10+ years)).

Question: How long is your "sleep window"? In other words, what time are you attempting to go to bed at night? And what time do you get up for the day?

I go to bed ALMOST ALWAYS between 10 and 11 (I take my sleeping pill between 9 and 10 depending on how close Im paying attention to the time)
I wake up between 5 and 5:30. There's really no reason for me to get up at that time, though for some reason, tired or not, I just assume it's time to get up, so I stay up, the days I've tried to go back to sleep, it just doesn't seem to happen. And it's very hard for me to go to sleep when there's light coming in the window.(maybe I should put something heavier over the window!)

Question: How do you make the decision to lay in bed even afer it's become clear that you are NOT falling back asleep relatively quickly?

depends. I've laid there for hours, though I've gotten to the point (I think?) where when I wake up, I 'know' if I've going to be able to fall back asleep right away, so I either lay down and go back to sleep or get up, do something for about an hour, then go back to bed, and usually I'll fall asleep almost immediately. On rare occasion, I'll just be 'done' sleeping for the day. This usually happens around 2:30

Question: What do you do when you first become aware that you are awake in the middle of the night? Do you look at the clock as soon as you first wake up? Do you immediately focus on the fact that you are AWAKE yet again and start worrying about why you are awake?

I do search for the time. the only clock by me is my cell phone, so I have to find my cell phone and press the button to turn the screen on to see the time. I don't THINK I start wondering why I woke up, I think I've let that go until I actually get up for the day. I do get disturbed that I'm awake again though.

Question: How much caffeine do you consume before 3:00pm in an average day?

oh god, not a clue, though not nearly as much as I used to, probably 3-4 12 ounce glasses of mt. dew. Though strangely enough, as a child/teenager, I used to drink caffeine to go to sleep. (I've always been wired wrong. Non drowsy medicine puts me to sleep, where as night time formulas do nothing.)

Question: When you do eat between 8:00pm and 9:00pm, what kinds of things do you eat?

salad or popcorn or carrots (usually popcorn though)

Question: When you go to bed at 10:00pm, are you genuinely sleepy? Or are you just exhausted?

neither. I take a sleeping pill at 9, which makes me sleepy at 10. if I don't take the pill, about 10 my brain becomes highly active and wants to start figuring things out (writing programs, working on finances, designing new ideas). If I don't take the sleeping pill, I wouldn't get tired till around 6am.

Question: What does the rest of your sleep hygiene look like?

huh? I know what sleep is, and I know what hygiene is, but I don't know exactly what sleep hygiene is?

Question: How much ambien are you taking? Are you taking 1-2 5mg tablets? Or is the middle of the night dose a smaller dose?

I take 5 mg ambien, one a night. I took 2 at once, and apparently was sleeping walking, so I split it up 1 an hour before bed, and one when I woke up in the middle of the night, but the one in the middle of the night made no difference on how I slept/woke the rest of the night, so I just stopped taking the second one.

Question: Are you taking ambien every night an hour before bedtime? Or are you taking only on some nights?

every night. I did it for 2 years, then my doctor prescribed me nortriptyline (for anxiety) but mistakenly told me to take it in the mornings, and I found it made me really tired, so I asked the doc about it, and she told me it was suppose to be taken at night, so I started taking it at night, and it helped me sleep really well, but then I couldn't pee, and that's kind of important, so I stopped taking it and went back to ambien.

Question: Are you taking Ambien CR or just plain old Ambien? It makes a difference.

Ambien. my insurance won't cover CR.

Question: When you do take the second dose after you first wake up in night, is that second dose effective at helping you get back to sleep? Does taking the second dose help prevent or minimize the number of additional wakes after that first wake?

I think I answered this earlier. Second one does nothing noticeable. I don't know if this is the way it's suppose to work or not, but it takes an hour before the pill has any effect on me, and with the second one, by then I'm usually back asleep anyways, and I still wake up between 5 and 5:30 regardless.

By taking the Ambien a full hour before you go to bed, it seems like you are both reducing the effeciveness of the drug for helping you get to sleep AND you are reducing the amount of Ambien in your body while you are asleep AND that makes he Ambien even less effective at preventing the night time wakes.

I guess that clarifies my last comment. But yeah, Ambien does nothing for me for about an hour. Then SUDDENLY I become groggy and a little uncoordinated, so I stumble to bed. If I go to bed before that, I lay there and get all stressed that I can't sleep, and stay awake longer.

Observation: If I were you, I'd talk to the doc (at length) to double check the instructions on how to take the Ambien. I'd also ask the doc for information about why he wants you to take it an hour before going to bed when the usual guidelines are to take it just before you climb into bed.

The doc doesn't tell me to take it an hour before bed. She's told me I should take it right before bed and it should work almost immediately. See last answer...

[Pugsy]

http://healthysleep.med.harvard.edu/hea ... oming/tips

Google good sleep hygiene and bad sleep hygiene and you will see what sleep hygiene is
I linked to one starting point above.
Will give you something to read till Robysue gets off the road.

[BryanC]

As Pugsy points out: The timing of that first wake is about 2 hours after you went to bed, and it could easily be a normal post-REM awakening. (More on these later.) The second wake looks like it happened about 2.5 hours after you went back to bed. It's possible that this might still be a post-REM awake. Or it's possible that you were pretty restless for sometime before the wake. Any ideas on how restless you were after you went back to bed at 0:35? And did you take an Ambien at either of these wakes?

It's possible I woke and laid there with the mask on trying to go back to sleep. I do that occasionally too. As for how restless, do you mean how long it took me to go back to sleep? No, that I don't know, it's possible also though, some nights I'll lay there with the machine running for quite a while before I fall asleep

Question: When you first become aware of the fact that you are AWAKE what do you do? I mean when you are still in bed---what's the first thing you think about or the first thing you do? Do you immediately look at the clock? Do you start worrying about the fact that you are awake again? Do you expect or worry that you won't be able to quickly fall back asleep? Do you start trying to figure out why you are awake?

Yes, but worse than that. I have to look for my phone, then press the button to wake it up so I can see the time. I do really need to stop that. I always worry that I won't be able to fall back asleep, but generally, I 'know' when I'm not going to be able to get back to sleep. That's the extended periods with the machine off. I've long since given up on trying to figure out WHY I wake up.

If those are the kinds of things that start going through your mind when you first become aware of the fact that you are awake, then you are likely making the wake last longer and you are making it harder to get back to sleep.

Here's something to keep in mind: Even people with perfectly normal sleep patterns (no OSA and no insomnia) typically wake up a few times each night---most often right at the end of a REM cycle. The thing is non-insomniacs respond very differently to the wake than insomniacs do: When non-insomniacs wake up, they typically determine that there's nothing external that needs their attention like a crying baby or some other night time emergency. And after quickly determining that there's no reason they need to be awake, they turn over, snuggle back into the covers, and go right back asleep. In the morning, they probably won't even remember the wake because the wake lasted less than 5 minutes. (In order to remember a wake in the morning, it typically needs to be at least 5 minutes long.)

Definitely me. I worry about everything that isn't 100% exactly 'right'. and I worry excessively. I would guess that wakes are at the end of REM cycles, because (now) I remember my dreams though those are getting pretty weird (dreams that is) And I do wonder why I woke, and that does slow my going back to sleep. I need something to not worry!

as for the rest of the post, I have not found anything to help me relax. I convince myself I can't relax cause I have too much to do.

[robysue]

Just a quick note to Bryan.

I have read your notes. They'll give me something to think about on the drive, and I probably will write something before I go to bed once we get to St. Paul.

For now, read what Pugsy has posted about sleep hygiene. You might also want to pick up a copy of Sound Sleep, Sound Mind by Dr. Barry Krakow.

[avi123]

"huh? I know what sleep is, and I know what hygiene is, but I don't know exactly what sleep hygiene is?
robysue wrote:
Question: How much ambien are you taking? Are you taking 1-2 5mg tablets? Or is the middle of the night dose a smaller dose?


I take 5 mg ambien, one a night. I took 2 at once, and apparently was sleeping walking, so I split it up 1 an hour before bed, and one when I woke up in the middle of the night, but the one in the middle of the night made no difference on how I slept/woke the rest of the night, so I just stopped taking the second one.

robysue wrote:
Question: Are you taking ambien every night an hour before bedtime? Or are you taking only on some nights?


every night. I did it for 2 years, then my doctor prescribed me nortriptyline (for anxiety) but mistakenly told me to take it in the mornings, and I found it made me really tired, so I asked the doc about it, and she told me it was suppose to be taken at night, so I started taking it at night, and it helped me sleep really well, but then I couldn't pee, and that's kind of important, so I stopped taking it and went back to ambien.
robysue wrote:
Question: Are you taking Ambien CR or just plain old Ambien? It makes a difference.
Ambien. my insurance won't cover CR.
robysue wrote:
Question: When you do take the second dose after you first wake up in night, is that second dose effective at helping you get back to sleep? Does taking the second dose help prevent or minimize the number of additional wakes after that first wake?

I think I answered this earlier. Second one does nothing noticeable. I don't know if this is the way it's suppose to work or not, but it takes an hour before the pill has any effect on me, and with the second one, by then I'm usually back asleep anyways, and I still wake up between 5 and 5:30 regardless.

robysue wrote:
By taking the Ambien a full hour before you go to bed, it seems like you are both reducing the effeciveness of the drug for helping you get to sleep AND you are reducing the amount of Ambien in your body while you are asleep AND that makes he Ambien even less effective at preventing the night time wakes.
I guess that clarifies my last comment. But yeah, Ambien does nothing for me for about an hour. Then SUDDENLY I become groggy and a little uncoordinated, so I stumble to bed. If I go to bed before that, I lay there and get all stressed that I can't sleep, and stay awake longer.
robysue wrote:
Observation: If I were you, I'd talk to the doc (at length) to double check the instructions on how to take the Ambien. I'd also ask the doc for information about why he wants you to take it an hour before going to bed when the usual guidelines are to take it just before you climb into bed.

The doc doesn't tell me to take it an hour before bed. She's told me I should take it right before bed and it should work almost immediately. See last answer."


Comments,

I am taking 5 mg Zolpidem (generic Ambien) every night before sleep. It helps me fall asleep within 15 min. It makes no difference if I take it 2 hours or 10 min before I go to sleep. On those occasions that I don't fall asleep within 0ne hour I take another 5 mg. At times I take the 2nd 5 mg during the night but never after 4 a.m. I need 8 hours to metabolize the Zolpidem and avoid any hang overs. There are times that I take the full 10 mg after an hour or two of sleep. I weigh 230 lbs @ 6' 2" (BMI ~= 30= obese). The dose is related to the person's weight. The two ladies who posted above are physically small. So if they take a 3 mg Zolpidem it should be equivalent to me taking 5 mg and even 10 mg. Luckily, I am retired and don't need to go to work in the morning. Otherwise, I would not take any Zolpidem after 3 a.m. I use a walker during the night when I go pee, to avoid losing my balance. No falls for me!

See here that Zolpidem has been rated by the Consumer Reports Best Buy Drugs as BEST sleep medication:

[BryanC]

I am taking 5 mg Zolpidem (generic Ambien) every night before sleep. It helps me fall asleep within 15 min. It makes no difference if I take it 2 hours or 10 min before I go to sleep. On those occasions that I don't fall asleep within 0ne hour I take another 5 mg. At times I take the 2nd 5 mg during the night but never after 4 a.m. I need 8 hours to metabolize the Zolpidem and avoid any hang overs. There are times that I take the full 10 mg after an hour or two of sleep. I weigh 230 lbs @ 6' 2" (BMI ~= 30= obese). The dose is related to the person's weight. The two ladies who posted above are physically small. So if they take a 3 mg Zolpidem it should be equivalent to me taking 5 mg and even 10 mg. Luckily, I am retired and don't need to go to work in the morning. Otherwise, I would not take any Zolpidem after 3 a.m. I use a walker during the night when I go pee, to avoid losing my balance. No falls for me!

to be quite honest, Zolpidem (which is what I take too, it's just easier to type Ambien ) up until the nortriptyline, was the only sleeping pill that ever worked for me. Though if I take the pill and immediately go to bed, I will toss and turn for several hours, and start worrying about not getting to sleep, and some nights the worry will win and I'll just not sleep. If I wait an hour, I (almost) always fall asleep within a few minutes of laying down. I know it's not how it's suppose to work, and obviously it's not going to last an hour longer just because I waited an hour, but even if I only get 2 hours of sleep, that's better than none

[robysue]

BryanC,

I'll write more tomorrow.

I've been using generic Ambien (i.e. Zolpidem) on an as needed basis for quite some time, and at certain points during the last year I have been told to take it nightly. It does help with the bedtime insomnia. It does little or nothing to really address the problem of sleep maintenance insomnia when that's my main problem.

So my most important question for you right now is this: In your opinion is bedtime insomnia or sleep maintenance insomnia the bigger issue right now?

Bedtime insomnia is the problem of falling asleep at an appropriate bedtime where YOU determine what an appropriate bedtime should be. Sleep maintenance insomnia is the inability to stay asleep once you get to sleep at the beginning of the night. In sleep maintenance insomnia the problem can either be too many middle of the night wakes OR it can be that it takes too long to get back to sleep once you are awake OR both.

Some other thing that I've been thinking about:

You currently have a (roughly) 10:00 or 11:00 pm bedtime and you tend to get up by around 5:30 am on a daily basis. So you have a sleep window that is between 6.5 and 7.5 hours long. You take the Ambien so that you can fall asleep by 11:00 because if you didn't, you wouldn't get sleeping until much, much later. You also say that if (when?) you take the Ambien right before going to bed, you lie in bed for "several hours" tossing and turning before being able to fall asleep.


If you didn't have any obligations like the job or family obligations that dictate that you must be up and functioning at certain times, when do you think your body would like to be asleep? Most of us have a natural circadian rhythm that allows us to more readily fall asleep at certain times, but those times may or may not fit our lifestyle. When our circadian rhythm doesn't match our lifestyle, it can result in some pretty significant sleep problems.

And I also have three more questions about what you think or believe your sleep should be like if it were "good" sleep rather than the bad sleep you are currently getting:

1) How long do you think it should take you to get to sleep at night when you first go to bed? How long does it take you to get to sleep when you take the Ambien in the way that seems to work the best for you?

2) How long do you think it should take you to get back to sleep after you wake up in the middle of the night? How long do you give yourself to get back to sleep before throwing in the towel and just getting up out of bed for a while?

3) How uncomfortable are you if you find yourself lying in bed for 15-20 minutes before falling asleep or falling back asleep after a wake? Is the discomfort mainly physical---i.e. your stomach is uncomfortable from the CPAP air being blown down your throat or your hips or back start to hurt from lying down in a certain position? Or is the discomfort mainly mental---i.e. you start to worry about not getting to sleep or you start to feel anxious because you are sure you won't be able to get (back) to sleep?

[BryanC]

So my most important question for you right now is this: In your opinion is bedtime insomnia or sleep maintenance insomnia the bigger issue right now?

I think it's more sleep maintenance that's the bigger issue right now.

You currently have a (roughly) 10:00 or 11:00 pm bedtime and you tend to get up by around 5:30 am on a daily basis. So you have a sleep window that is between 6.5 and 7.5 hours long. You take the Ambien so that you can fall asleep by 11:00 because if you didn't, you wouldn't get sleeping until much, much later. You also say that if (when?) you take the Ambien right before going to bed, you lie in bed for "several hours" tossing and turning before being able to fall asleep.

Did I say that? I might have, but I GENERALLY take the Ambien at 9 and go to bed around 10. (last night I took it at 10, and went to bed by 10:30 I'm sure, I remember looking at the clock when I went to bed.... but sleepyhead says I started using the machine at 11:30?! But it says I woke up at 4, and I did wake up at 4?! (I did not look at the clock, but I was awake enough/tummy rumbling to know I wasn't getting back to sleep.)... Then I tried for 40 minutes to go back to sleep, but, no luck. So, I guess I'm up for the day.

Though I had NO obstructive apnea's last night, I did have 10 clear airway apnea's, but those didn't really look like anything more than hypopena's (not really sure how serious those are, but the breathing pattern looks almost normal during them.)

If you didn't have any obligations like the job or family obligations that dictate that you must be up and functioning at certain times, when do you think your body would like to be asleep? Most of us have a natural circadian rhythm that allows us to more readily fall asleep at certain times, but those times may or may not fit our lifestyle. When our circadian rhythm doesn't match our lifestyle, it can result in some pretty significant sleep problems.

Honestly, I don't have any reason for going to bed at an specific time, or getting up at any specific time. Realistically, I would go to bed around 1am (I am exhausted all day long till about 9 or 10 but then I get a burst of energy? and I'm wide awake (assuming I didn't take my ambien ) Though, regardless of what time I go to bed, I tend to wake up around 5.

1) How long do you think it should take you to get to sleep at night when you first go to bed? How long does it take you to get to sleep when you take the Ambien in the way that seems to work the best for you?

Everyone else I know lays down and falls asleep almost immediately. I would be happy if I could do it in under 10. If I take Ambien an hour before laying down, I do fall asleep almost immediately after laying down. (I did take it only 30 minutes before bed last night, and fell asleep almost immediately, though I also slept a hour less.... So, I'll try 30 minutes before bed for a week and see how that works, then if it looks the better or even the same, I'll move up to immediately before bed and see how that works.)

2) How long do you think it should take you to get back to sleep after you wake up in the middle of the night? How long do you give yourself to get back to sleep before throwing in the towel and just getting up out of bed for a while?

I think after waking up in the middle of the night, I should be able to fall back asleep within a few minutes. Sometimes that happens, sometimes it doesn't. and generally I 'know' when I'm going to be able to get back to sleep so I'll close my eyes, and poof, I'm out. But other times when I'm not completely sure, or have a small hope it could happen, I'll try for 30-60 minutes.

How uncomfortable are you if you find yourself lying in bed for 15-20 minutes before falling asleep or falling back asleep after a wake? Is the discomfort mainly physical---i.e. your stomach is uncomfortable from the CPAP air being blown down your throat or your hips or back start to hurt from lying down in a certain position? Or is the discomfort mainly mental---i.e. you start to worry about not getting to sleep or you start to feel anxious because you are sure you won't be able to get (back) to sleep?

the only discomfort would be when I wake up hungry. The CPAP rarely causes me any pain. Sometimes (often for spells, then none for a while) I'll wake up with a dry throat, but a quick drink, and I'm fine. Though the anxiousness kicks in after laying awake for even only a few minutes (or, of course, if I have something I have to do the next day.)

[robysue]

BryanC,

Now for the really long post responding to the stuff you've already written.


First, let's start with sleep hygiene, which you're not particularly familiar with. I hope you have read the link Pugsy posted about it. Loosely sleep hygeine refers to behavior patterns that directly (or indirectly) affect the quality of your sleep. Good sleep hygiene are behavior patterns that are thought to encourage better sleep---i.e. falling asleep faster at the beginning of the night, minimizing night time wakes and falling back asleep quickly after the few random wakes anybody is likely to have during the night. Bad sleep hygiene are behavior patterns that tend to make the sleep worse---they tend to make it harder to fall asleep quickly, tend to increaase the number of middle of the night wakes, tend to increase the length of each middle of the night wake, and encourage overall "restlessness" when you are in bed you are supposed to be sleeping.

Most insominacs have a number of behavior patterns that clearly fall into bad sleep hygiene. Some insominacs are lucky enough to be able to control their insomnia by simply being quite vigilant about their sleep hygiene. Other insomniacs find that a combination of good sleep hygiene and appropriate use of prescription sleeping medication is needed to control their insomnia. A few insomniacs can seem to control the insomnia by just taking meds without working on the sleep hygiene at all, but typically most docs who prescribe a sleeping med will tell the patient to pay attention to some of the big, broad guidelines of good sleep hygiene.

From what you've written so far, it looks like your sleep hygiene is a mixed bag.

The Good
1) You do seem to have a fairly stable "sleep window"---i.e. you go to bed about the same time each night and you get up at the same time each morning---as in seven days a week. Most insomniacs don't do well long term with a "work schedule" followed by "sleeping in on the weekends".

2) You are also aware that lying in bed for long periods of time fretting about the fact that you are not yet asleep is not a good idea. And you are willing to get out of bed after a middle of the night wake when you know you're not going to be able to get back to sleep. That's a standard thing insomnias are told to do. The rationale behind this is that you have to train your body and mind to both accept that Time in Bed = Time to Sleep, and if the mind (or body) refuses to cooperate, then you get up until you are sleepy enough to go back to bed and try again.


The Bad
1) You are a clock watcher:

Question: When you first become aware of the fact that you are AWAKE what do you do? I mean when you are still in bed---what's the first thing you think about or the first thing you do? Do you immediately look at the clock? ...

Yes, but worse than that. I have to look for my phone, then press the button to wake it up so I can see the time. I do really need to stop that.

You've already tried to make it harder to wake up and look at the clock---but instead of helping things, you're currently so trapped by the need to establish what time is it? when you wake up, that you are forcing yourself to become much more fully awake and conscious by the need to fumble around for the pone and then turn the damn phone on. All that mental activity is causing the wake to be LONGER than it needs to be.

So the first thing you need to do is answer this question for yourself: Why is it so important to know the time when you wake up? What possible good can come of knowing the time?

If you simply have to know how many wakes you have each night and when they each occur, I would suggest using the CPAP to document the small wakes: Turn the machine OFF and then back ON without looking for your cell phone to figure out what time it is. In the morning, you can download the data and you'll be able to see each and every wake during the night.

2) You are a worrier and you fret about BEING awake in the middle of the night and you fret about NOT being able to sleep:

I do get disturbed that I'm awake again though.

But yeah, Ambien does nothing for me for about an hour. Then SUDDENLY I become groggy and a little uncoordinated, so I stumble to bed. If I go to bed before that, I lay there and get all stressed that I can't sleep, and stay awake longer. (emphasis added)

I always worry that I won't be able to fall back asleep, but generally, I 'know' when I'm not going to be able to get back to sleep.

I worry about everything that isn't 100% exactly 'right'. and I worry excessively. I would guess that wakes are at the end of REM cycles, because (now) I remember my dreams though those are getting pretty weird (dreams that is) And I do wonder why I woke, and that does slow my going back to sleep. I need something to not worry!

Identifying the problem is easier than fixing it---particularly since you go on to say:

as for the rest of the post, I have not found anything to help me relax. I convince myself I can't relax cause I have too much to do.

As my dear hubby keeps reminding me: It's hard work to genuinely relax. But it is critical to figure out some ways of helping yourself to consciously relax. It's not a matter of being too busy to find time to relax: It's a matter of understanding that allowing yourself to consciously relax for at least a short period every single day will (eventually) make you much more effective at getting all those things that have to be done done.

There are several ways of tackling the worrying and fretting that leads to anxiety, particularly about sleep issues: You can learn to take some time to relax every day. Or, if the anxiety is severe, you can take anti-anxiety medication. Or you can do both. Only you and your doctor can figure out whether or not you should be on anti-anxiety medication. But learning how to consciously relax is something that you should do regardless of whatever else you decide to do.

And learning to relax is NOT about taking great gobs of time away from "other things". Sometimes it's as simple as learning some breathing techniques (often based on yoga) that allow the brain to settle down within a minute or two of focused breathing.

A practical suggestion: When you find yourself awake, don't immediately reach for the cell phone. Do turn your machine OFF and take your mask off and then take a series of 5-10 really nice, deep diaphragmatic, cleansing breaths without the machine on. Focus your mind on the breathing---notice the way you can sense the (cooler) air moving into the nose and the (warmer) air moving out of the nose with each breath. Focus your mind on how your body feels. It is comfortable? Too hot? Too warm? Pain in the back? hip? neck? After finishing the 5-10 breaths, deal with the comfort issues that you've noticed. And once you are comfy again, mask back up and turn the machine back on and allow yourself to believe that you'll get back to sleep. And give yourself what you think is about 15-20 minutes to get back to sleep, but NO cheating by looking at the clock. If you haven't gotten back to sleep in about 15-20 minutes, go ahead and get up and then do something relaxing when you are out of bed.


The Ugly
1) Caffeine. You're aware that you need to limit it, but you may need to eliminate all caffiene after noon rather than 3:00pm. You may also need to eliminate all caffiene. Or you may need to look for hidden caffiene sources, including chocolate.

2) Evening snacking. You're eating a carb-rich bedtime snack about an hour before going to bed. Usually that's not a problem---provided it is really snack sized. But a lot of us eat snacks that are larger than snack sized. You might also want to consider what you are eating for supper as well as the bedtime snack.

3) Bedroom environment. You say you can't sleep once the morning light comes in the window around 5:30. If getting up at 5:30 is fine with you, there's no problem. If you really and truly want to sleep later (so that bedtime can be later than 10:00 or 11:00), then darkening the room with different curtains/blinds may be worth while. Also check to make sure your bedroom is sufficiently quiet, but not too quiet, for sleeping. And that the temperature is cool enough for good sleeping.


The Unknown
1) Closure. I suspect that you have some closure issues since you write:

I take a sleeping pill at 9, which makes me sleepy at 10. if I don't take the pill, about 10 my brain becomes highly active and wants to start figuring things out (writing programs, working on finances, designing new ideas). If I don't take the sleeping pill, I wouldn't get tired till around 6am. (emphasis added)

Closure is the abililty to turn off the mind at bedtime. It's hard to sleep soundly if your brain keeps up a conversation with itself all night long. Sometimes closure is just letting today (and today's issues) go. Sometimes closure is the ability to tell the brain to shut up about things that can/should/will be done tomorrow. Dr. Krakow has a lot to say about closure issues in Sound Sleep, Sound Mind.

2) Bedtime routine. Other than taking the sleeping pill a full hour before you intend on going to bed, what do you do before going to bed? In particular, what do you do after you take the Ambien and before you crawl into bed? Lots of computer time? Lots of TV watching? Lots of reading highly technical material that you have to be wide awake to understand? You need a relaxing bedtime routine that helps your mind unwind and settle down and prepare for sleeping. What that routine is is not particularly important---as long as it is focused on allowing the mind to quit thinking a mile a minute ...

3) Activities when you ARE out of bed because you can't sleep. You've said that you get up when you know you're not going to be able to quickly get back to sleep. But what do you do when you are out of bed? Ideally you should be doing things that encourage your mind to grow sleepy enough to go back to bed and return to sleep. In other words, ideally you should be doing things that are consciously relaxing for your mind and body. But a lot of insomniacs will gravitate to activities that stimulate more wakefulness once they're out of bed. A short list of do's and dont's might include:

• Good activities to do when you are out of bed because you can't sleep:
  • Sit in the dark listening to quiet music
  • Sip a cup of sleepy time tea or warm milk
  • Read a boring book---a real book, not something on-line
  • Work a real crossword or sudoku that's printed on real paper with a real pen or pencil
  • Pet the cat or dog if you have one
  • Meditate
  
  
  Bad activities to do when you are out of bed because you can't sleep:
  • Paperwork for the job; anything job related at all in fact
  • Planning for tomorrow---going through the long list of "things to do"
  • Looking at the clock repeatedly
  • Worrying or fretting about the fact that you are NOT asleep in your bed.
  • Reviewing the previous day's "to do list" and fretting about how many things did NOT get done
  • Getting online and web browsing. The blue light from computer monitors and cell phones is bad for the melatonin cycle.
  • Reading a book that you can't put down because it's so interesting.
  • Computer games
  • Intense exercise

[BryanC]

wow, that was a lot, and definitely so good advice. I've forgotten much of it already, but I'll read it again without thinking about what to say in reply. I will try some of your suggestions (maybe all, again, I've forgotten, I have a bad short term memory, but it will all come back to me soon) over the next few days to see if they help and if I can get in the habit of doing them. I just got back from the doctor too, and he put me on some new pills (trazidon?) to help me stay asleep, so hopefully that'll help too. Hopefully tomorrow I'll be a little more clear headed (sorry if there was stuff I should have replied to, I will in the next day or so, I promise, I'm just really really not thinking well at the moment... way too tired )