CPAP seems successful, but still having sleeping issues

[aroeske]

I have always had issues falling and staying asleep, but in the past few years it seems to be worsening. The best way I can describe it is I can't turn my brain off. I can be so tired I can't see straight and have problems falling asleep. I cannot nap, unless I am sick.

So I talked to my nurologist (I suffer from migraine as well), and he ended up giving me amitriptaline 50mg before bed. When I take it, I do feel I sleep better, but am still dragging in the morning. If I forget to take it, it's a long night. Then I went to my GP who wanted a sleep study, which showed I had severe OSA (AHI of 75). I have been on CPAP Since Feb 23, 2017, and its seems to be working great. My AHI is usually between 0.5 and 2. I tolerate the mask very well and have no issues sleeping with it. While I can say I feel physically much better now, I still have the same issue as before. My doc also ran blood work and my Vitamin D was very low, and I'm working that back up.

I had a message from the doctor office today saying if I didn't improve, they were going to refer me. I'm not sure to whom yet, but I haven't had a chance to talk to them either.

So just wondering if anyone has any thoughts. I was really hopeful my problems were tied to the OSA, and gave it a couple months. I attached a snapshot of a typical night from sleepyhead for your viewing pleasure.

Thanks!

Andy

[robysue]

aroeske,

Your data looks excellent. And I'm sorry that you are still feeling like you are dragging in the morning.

Sometimes it just takes a bit more time before a person feels the full benefit of CPAP in terms of how they feel in the morning and throughout the day. You're 2.5 months into therapy, and it could be that you just need more time. And yes, I remember how awful it can feel to be told that you need more time when your data looks great and you're feeling awful. That's how I was for the first 5 or 6 months of PAPing.

It could also be that the amitriptaline dose is leading to the morning dragging. While amitriptaline is not a "standard" prescription sleeping pill, it is commonly prescribed off label as a sleep aid. With many of the standard prescription sleeping pills like Ambien, a common side effect is dragging in the morning and taking a long time to wake up. Sometimes a smaller dose of the medicine is still effective in terms of helping the person get to sleep, but doesn't create the morning dragging feeling. So you could talk to the doc who prescribed the amitriptaline and see if cutting back on the dosage is a worthwhile experiement.

It's also important to find out who the sleep doc is intending to refer you to.

[kteague]

I would be curious as to if your sleep in general looks as good as your cpap data looks. If your sleep is still not restful, talk to your doctor about having a sleep study done while using your cpap at its usual settings to see if there's anything else about your sleep that needs to be addressed. I do agree that you are still fairly new to this and recovery may be taking you longer than you'd hoped. And then there's the medicine thing. But especially if your sleep still feels restless, consider another sleep study as described above.

[Pugsy]

Are you still taking the Amitriptyline 50 mg at bedtime? If so....at what time do you take it and when do you go to bed and when do you usually get up?

I am familiar with this medication in lower doses as a sleep aid....I am in agreement with RobySue...maybe reduce the dosage.
If I took 50 mg at bedtime I am not sure I could even make to the "walking zombie" category. Most likely would be the horizontal like dead zombie.

Besides the low vitatmin D....any other health issues? Take any other meds?
Pain? Arthritis?
Bed comfort?
Anything that affects falling asleep or staying asleep?

[LSAT]

On occasion I use Amitriptyline to help me sleep, but I only take half of a 10mg and it knocks me out. If I take the full 10mg I'm groggy for an hour after trying to get up.

[aroeske]

Thanks for the replies everyone.

Yes I still take 50mg. I usually take it around 8. That dose will make me a bit drowsy, but it doesn't knock me out by any means. Right now its been 2 hours since I took it and the last thing I feel like doing is sleep; but I'm tired, just not sleepy. I try to go to bed at 10-10:30 and up at 6:45. Sometimes I wonder if I am subconsciously afraid of sleep. I have tried taking 25 mg, but usually I get no effect from it.

Other than the Vitamin D, everything else comes back good on the blood work. I do get migraines, but usually only about every 3 months or so, and I take Treximet as needed for those.

The mattress I have is pretty good, and only 3 years old. I don't think I have an issue with comfort.

As far as anything that may cause me to not fall to sleep? I would honestly say that the fear of not sleeping probably is high on that list. That is actually a pretty recent revelation; and is a pretty vicious cycle.

Has anyone here tried CBT-i? I was looking at some things about sleep hygiene, and I don;t do too well in that department....

Andy

[Pugsy]

Has anyone here tried CBT-i?

Forum member RobySue has some fairly extensive experience with CBT.
http://adventures-in-hosehead-land.blog ... er_19.html
as well as some recent in depth comments she made in this thread about insomnia and CBT
viewtopic.php?f=1&t=116810&st=0&sk=t&sd=a&start=15
She will probably stop back here to your thread and comment further.

If reducing the amitryptiline doesn't work well because you then simply can't go to sleep but the 50 mg dosage causes too much of a problem the next day perhaps discuss the issue with your doctor to maybe consider taking something else that doesn't have as long of a half life as the Amitryptiline does....so less likely to cause unwanted symptoms the next day.
That's why I take 10 mg instead of 20 mg....I still get a bit of a hangover thing the next morning but it isn't nearly as annoying as 20 mg gives me.
I don't take it for sleep onset insomnia though...I take it for sleep maintenance insomnia caused by pain. It helps me "sleep through" minor aches and pains that would otherwise cause highly fragmented sleep from waking up every time I move in bed which is often.
Last summer I did try going without it for 3 months because of the residual grogginess was annoying but I discovered that the poor sleep quality from the many more wake ups caused more daytime unwanted symptoms than the amitryptiline caused so I went back to it. That devil was less annoying than the poor sleep quality devil. While I don't feel so great sometimes when I take it I have found I feel worse when I don't take it because my overall sleep quality gets trashed by many more wake ups from the pain.

Talk to your doctor about your options....you do have other choices all the way from different meds to the CBT.

[EdNerd]

CPAP treats apnea, not sleep. Apnea definitely affects sleep, but it may not be the only thing affecting your sleep. In fact, correcting the apnea issue will allow other issues to come to light.

I would recommend finding a sleep specialist that looks at other things besides breathing. You mention not turning your mind off - do you have anxiety issues? Depression or other disorder? What about pain? Or stress? PTSD?

Sleep hygiene can be a big deal: what you eat and drink and when; the environment you must sleep in; who or what sleeps with you; what you do right before getting into bed; etc. As far as environment: how's the temperature? noise level? others jostling you or snoring at night? animals need to go out? Do you have to make a lot of bathroom trips?

All things to consider. And all things a good sleep doc will ask.
And one who's just making bank off sleep studies and CPAP will ignore!

Ed

[aroeske]

Pugsy, Thanks for that thread, I missed it. It was a very interesting read. With the amitryptaline, yeah finding the balance between feeling groggy from the med vs feeling groggy because of no sleep has been a challenge. As I work for a pharmacy chain, I have had plenty of advice on supplements, and over the counter items. And so far this is the best I have found.

EdNerd, I have had anxiety issues in the past. I have a tendency to overthink everything. I personally think this could be part of it, but I swore I didn't have OSA either, that's why I'm not a Doctor.

I will be calling the doctor to get the referal Monday. It has been 'fun' week at work. We'll see where this goes.

I appreciate the perspective from everyone!

Andy

[TASmart]

In my case a racing brain was a huge warning flag that depression and/or anxiety were setting in for one of their periodic visits. I notice that since starting CPAP I have a much easier time falling asleep and going back to sleep when I wake at night. From what I understand CBT - I can be very useful for helping to calm the mind, as can meditation and mindfulness training. In my case I can quiet things down with SSRI medication but I do not like that too much, so as of recently I am off Zoloft, and feeling awfully darn good. Thanks to getting adequate sleep.

[aroeske]

Thanks for the input everyone. As an update all the referral said on it was refer to Sleep Medicine. So after trying to find out from the Drs office what I am to do with this for two weeks (I still haven't received a call back), I contacted the office of the Dr that read my sleep studies. They said it would be August or September before I would get in. Heaven forbid if I happen to actually having sleep problems... *rolling eyes*.

In the mean time I will likely try some of the suggestions on here. I did try cutting the Amitryptaline down to 25mg at night I felt way worse the following day. So I am going back to 50mg for now.

Thanks again!

[MaryLand]

I, too, have had a history of not being able to turn my thoughts off at night and anxiety. However, I prefer to take a natural remedy as opposed to Rx drugs, and have found what works for me very well. I take over the counter amino acid supplements. I take 200mg of l-theanine and 1000mg of GABA. Sometimes I add 100-200mg of 5-HTP as well. Since I began taking these about 3 years ago, even before I was dx'd with apnea, it has been much easier to stop the churning brain at night and easier to fall asleep. Also, I never realized how anxious I was all the time, until I wasn't anymore. If I skip the GABA for more than one day, anxiety starts to return. These amino acids affect brain neurotransmitters, and your mileage may vary. I do not know how or if they interact with prescription medications, except I do know if you're taking SSRIs you need to be careful, especially with the 5-HTP. If you are not taking any drugs, they're very safe and usually free of side effects. You can start with one, or with lower doses, and play with it from there to find out what works. Another thing I can recommend is a spray called Ease Magnesium -- great to help you relax, calm your mind, and sleep better, along with helping aches and pains.