Is it sleep apnea or ain't it?

[Friendly]

Hi CPAP community,
I'm trying to get help for a friend. He posted this, then a troll kind of shut the conversation down (called me a liar and said we were one person posing as two?!), so there was no helpful advice. My friend discontinued posting to this forum. But he still needs support.

The latest is that 2 days ago a doctor (who is a pulmonologist, but not strictly a sleep specialist) said basically that he doesn't have sleep apnea and everything in the sleep study is in normal range.

His sleep specialist said he does, but I think his sleep specialist was one of those "CPAP is the gold standard" people who just throws a generic mask and machine at you and if it doesn't solve the problem right away she's all out of ideas.

I'm re-posting his sleep study data in the hope of getting more expert eyes and more support.

Thanks SOOO much!

Friendly





Impression:
1. CPAP setting of 6cmH2O effectively improved sleep disordered breathing during REM sleep and in the lateral position and stabilized oxygen saturation at 97%.

2. The patient slept 2.7 hours out of a total 7.1 hours bedtime monitored, yielding reduced sleep efficiency of 38%.
Latency to sleep onset was 34.5 minutes, which was prolonged.

3. EKG, EEG, and EMG were normal.


Diagnosis:

Axis I: Obstrctive sleep apnea (adult) (G47.33)
Axis II: CPAP Titration study, 95811


Recommendation:

1) Suggest a CPAP setting of 6-9 cm H2O
2) The patient preference was ResMed Mirage FX- standard nasal mask.
3) The UCLA Sleep Disorders Center offers mask-fitting consultations and positive pressure acclimation (PAP Nap) studies. Orders may be placed through CareConnect or faxed to the sleep center at (310) 267-1062
4) The patient should be advised not to drive when sleepy.
5) The patient should avoid long acting sedatives and alcohol close to bedtime.



The patient was referred for sleep testing only. Patient should return to the referring physician for follow up and management including prescribing Nasal CPAP for home use. For formal consultations with sleep specialist, please call 310-825-2631.

Electronically signed by

Karen Lee, M.D.
Diplomate, American Academy of Sleep Medicine




The following data based on technologist observation – subject to physician interpretation


A. GENERAL PARAMETERS MEASURED

Left and Right EOG EKG
Chin EMG Anterior Tibialis EMG
Abdominal Movement Thoracic Chest Movement
C-Flow Oximetry
EEG (F4-M1, C4-M1, and O2-M1) Snore Sound
Body Position



B. SLEEP SCORING DATA

1. Lights Out: 10:49 PM
2. Lights On: 5:54 AM
3. Total sleep time: 160 minutes (2.7 hrs)
4. Total recording time: 425 minutes (7.1 hrs)
5. Sleep Efficiency Index: 38%
6. Wake time: 265 minutes (Normal is equal or less than 20 minutes)
Stage N1: 22 minutes (14% of total sleep time. Normal: 5-15%)
Stage N2: 105 minutes (66% of total sleep time. Normal: 45-80%)
Stage N3: 12 minutes (8% of total sleep time. Normal: 0-15%)
Stage R: 20 minutes (13% of total sleep time. Normal: 12-20%)


7. Latency to sleep onset: 34.5 minutes (normal 10-20 minutes)
8. Wake after sleep onset: 231.0 minutes (Normal is equal or less than 20 minutes)
9. Latency to REM onset: 41.5 minutes (Normal is equal or greater than 90 minutes)

C. AROUSAL EVENTS
1. Total number of arousals: 64
2. Arousal index: 24/hr (Normal is less than 10/hr)

D. CARDIAC SUMMARY
Heart Rate Summary
Average heart rate during sleep: 51 bpm. Highest during sleep: 64 bpm. Highest of awake: 62 bpm

Cardiac Events:

(None)

Other Arrhythmia: Tech did not observe any arrhythmias during the study.


E. MOVEMENT EVENTS

LMs Index
PLMS 37 14/hr
PLMS with Arousal 16 6/hr



F. RESPIRATORY EVENTS

Respiratory Rate: 12-14 breaths per minute

The patient did not have Cheyne-Stokes breathing. CPAP was utilized at pressures ranging from 5 to 8 cm H2O. During the study, ResMed Mirage FX standard nasal mask was used.

CPAP (cmH2O) 5-8
Position Supine, Lateral
Sleep State REM, NREM
Baseline O2 Level 96-97%
Supplemental O2 None LPM
Minimum O2 Saturation 92.0%
Recorded Sleep Time 2.7 Hours
Apnea-Hypopnea Index (AHI) 1/hr
Apnea Index (AI) 0.7/hr
Hypopnea Index (HI) 0.0/hr
AHI on supine position 1/hr
AHI during REM sleep 3/hr




Pressure CPAP 05 06 07 08
Time TRT 221.5m 132.0m 44.0m 28.0m
TST 68.5m 42.0m 43.0m 7.0m
Total Events 1 0 0 1
Obs. Apn. 0 0 0 0
Mixed Apn 0 0 0 0
Resp. Central Apn. 1 0 0 1
Obs Hyp. 0 0 0 0
Cen Hyp. 0 0 0 0
AHI 0.88 0.00 0.00 8.57
Supine AHI 0.88 0.00 N/A N/A
Side AHI 0.00 0.00 0.00 120.0

Apnea/Hypopneas Index (AHI): Number of apnea/hopopnea episides per hour of sleep (Normal less than 5).
Hypopnea definition (AASM Rule 1B): A decrease in the nasal pressure signal amplitude of 30% or greater, lasting 10- seconds, with a 4% or greater oxygen desaturation from baseline
Respiratory Disturbance Index (RDI): Number of apnea, hypopnea, and respiratory effort related arousal (RERA)episodes per hour of sleep.

G. OXIMETRY SUMMARY

Percent time and time in minutes for each oxygen saturation range during sleep:


Oxygen Saturation Range Sleep time in minutes Percent of total sleep time
89-100% 160 100%
81-88% 0 0%
71-80% 0 0%
61-70% 0 0%
Artifact 0 0%

[Friendly]

More data:

Impression:
1. CPAP setting of 6cmH2O effectively improved sleep disordered breathing during REM sleep and in the lateral position and stabilized oxygen saturation at 97%.

2. The patient slept 2.7 hours out of a total 7.1 hours bedtime monitored, yielding reduced sleep efficiency of 38%.
Latency to sleep onset was 34.5 minutes, which was prolonged.

3. EKG, EEG, and EMG were normal.


Diagnosis:

Axis I: Obstrctive sleep apnea (adult) (G47.33)
Axis II: CPAP Titration study, 95811


Recommendation:

1) Suggest a CPAP setting of 6-9 cm H2O
2) The patient preference was ResMed Mirage FX- standard nasal mask.
3) The UCLA Sleep Disorders Center offers mask-fitting consultations and positive pressure acclimation (PAP Nap) studies. Orders may be placed through CareConnect or faxed to the sleep center at (310) 267-1062
4) The patient should be advised not to drive when sleepy.
5) The patient should avoid long acting sedatives and alcohol close to bedtime.



The patient was referred for sleep testing only. Patient should return to the referring physician for follow up and management including prescribing Nasal CPAP for home use. For formal consultations with sleep specialist, please call 310-825-2631.

Electronically signed by

Karen Lee, M.D.
Diplomate, American Academy of Sleep Medicine




The following data based on technologist observation – subject to physician interpretation


A. GENERAL PARAMETERS MEASURED

Left and Right EOG EKG
Chin EMG Anterior Tibialis EMG
Abdominal Movement Thoracic Chest Movement
C-Flow Oximetry
EEG (F4-M1, C4-M1, and O2-M1) Snore Sound
Body Position



B. SLEEP SCORING DATA

1. Lights Out: 10:49 PM
2. Lights On: 5:54 AM
3. Total sleep time: 160 minutes (2.7 hrs)
4. Total recording time: 425 minutes (7.1 hrs)
5. Sleep Efficiency Index: 38%
6. Wake time: 265 minutes (Normal is equal or less than 20 minutes)
Stage N1: 22 minutes (14% of total sleep time. Normal: 5-15%)
Stage N2: 105 minutes (66% of total sleep time. Normal: 45-80%)
Stage N3: 12 minutes (8% of total sleep time. Normal: 0-15%)
Stage R: 20 minutes (13% of total sleep time. Normal: 12-20%)


7. Latency to sleep onset: 34.5 minutes (normal 10-20 minutes)
8. Wake after sleep onset: 231.0 minutes (Normal is equal or less than 20 minutes)
9. Latency to REM onset: 41.5 minutes (Normal is equal or greater than 90 minutes)

C. AROUSAL EVENTS
1. Total number of arousals: 64
2. Arousal index: 24/hr (Normal is less than 10/hr)

D. CARDIAC SUMMARY
Heart Rate Summary
Average heart rate during sleep: 51 bpm. Highest during sleep: 64 bpm. Highest of awake: 62 bpm

Cardiac Events:

(None)

Other Arrhythmia: Tech did not observe any arrhythmias during the study.


E. MOVEMENT EVENTS

LMs Index
PLMS 37 14/hr
PLMS with Arousal 16 6/hr



F. RESPIRATORY EVENTS

Respiratory Rate: 12-14 breaths per minute

The patient did not have Cheyne-Stokes breathing. CPAP was utilized at pressures ranging from 5 to 8 cm H2O. During the study, ResMed Mirage FX standard nasal mask was used.

CPAP (cmH2O) 5-8
Position Supine, Lateral
Sleep State REM, NREM
Baseline O2 Level 96-97%
Supplemental O2 None LPM
Minimum O2 Saturation 92.0%
Recorded Sleep Time 2.7 Hours
Apnea-Hypopnea Index (AHI) 1/hr
Apnea Index (AI) 0.7/hr
Hypopnea Index (HI) 0.0/hr
AHI on supine position 1/hr
AHI during REM sleep 3/hr




Pressure CPAP 05 06 07 08
Time TRT 221.5m 132.0m 44.0m 28.0m
TST 68.5m 42.0m 43.0m 7.0m
Total Events 1 0 0 1
Obs. Apn. 0 0 0 0
Mixed Apn 0 0 0 0
Resp. Central Apn. 1 0 0 1
Obs Hyp. 0 0 0 0
Cen Hyp. 0 0 0 0
AHI 0.88 0.00 0.00 8.57
Supine AHI 0.88 0.00 N/A N/A
Side AHI 0.00 0.00 0.00 120.0

Apnea/Hypopneas Index (AHI): Number of apnea/hopopnea episides per hour of sleep (Normal less than 5).
Hypopnea definition (AASM Rule 1B): A decrease in the nasal pressure signal amplitude of 30% or greater, lasting 10- seconds, with a 4% or greater oxygen desaturation from baseline
Respiratory Disturbance Index (RDI): Number of apnea, hypopnea, and respiratory effort related arousal (RERA)episodes per hour of sleep.

G. OXIMETRY SUMMARY

Percent time and time in minutes for each oxygen saturation range during sleep:


Oxygen Saturation Range Sleep time in minutes Percent of total sleep time
89-100% 160 100%
81-88% 0 0%
71-80% 0 0%
61-70% 0 0%
Artifact 0 0%

Equipment:
AirSense 10 AutoSet

Serial Number 23171718078
Mode: AutoSet
Min Pressure 6cm H20
Max Pressure 9cm H20
EPR Fulltime
EPR level 3
Response Standard

Data for weeks seven through nine with cap:

Pressure: cmH2O
Median 6.8 95th percentile 8.3
Leaks
Median 0.4 95th percentile 105
Events per hour
AI: 2.2 HI: 0.1
Apnea Index:
Central 1.2 Obstructive : 0.8

[D.H.]

I don't think that the subject slept long enough to make a conclusive diagnosis. The patient clearly is having sleep difficulties, but it might be exaggerated due to being "all wired up" at the sleep lab.

If they want to try CPAP, I suggest giving it a shot.

Also, I suggest a sleep doctor who is also a neurologist, as this appears to be a rather difficult case and other sleep disorders might be present.

[Friendly]

Thank you, this is helpful.

I don't think that the subject slept long enough to make a conclusive diagnosis. The patient clearly is having sleep difficulties, but it might be exaggerated due to being "all wired up" at the sleep lab.

If they want to try CPAP, I suggest giving it a shot.

Also, I suggest a sleep doctor who is also a neurologist, as this appears to be a rather difficult case and other sleep disorders might be present.

[ChicagoGranny]

Friendly

The data you posted is confusing. Is that a titration study? In a titration study, you are sleeping with CPAP running. The CPAP is preventing some events, so you don't know what the patient's condition is without CPAP. For this, you need a diagnostic study. Insurance requires a diagnostic study. Was a diagnostic study undertaken?

[zoocrewphoto]

It looks like the data is all from a titration study. You need to post the data from the first study without cpap. That will show what untreated sleep looks like.

[jnk...]

If CPAP improves someone's sleep, that's all that matters.

Everything else is insurance-based mumbo-jumbo.

It don't matter what name you call it.

[Friendly]

Hey, thanks everybody, got the original sleep study:


Sex: male BMI: 24 kg/m2
Age: 31.2 Type of Study: PSG
UCLA#W5142418 Referring Physician: KAREN LEE
CSN: 90046733428 ESS: 14/24†
Test Date: 5/22/2017 PHQ-9 Score: 10/27‡
† Epworth Sleepiness Scale (ESS): A score of ? 10 signifies
excessive sleepiness.
‡ Patient Health Questionnaire-9 (PHQ-9) Score: Normal less than
5.
Main complaint: Possible sleep apnea, Daytime sleepiness,
Snoring.
Medications: See chart (to view meds in CareConnect, use the
smart phrase.cmed).

An overnight diagnotic sleep study was performed on 5/22/2017. A
Summary and detailed report of the sleep study is provided. The
interpreting physician has reviewed the referral, clinical
history, medical notes, patient's sleep questionnaire, sleep
technologist's notes, and raw data epoch by epoch.

Impression:
1. The study demonstrates sleep disordered breathing with an AHI
of 2/hr, RDI 11/hr, worse during REM sleep. The respiratory
disturbances were associated with mild oxygen desaturations down
to 90.0%. Baseline oxygen level was 96.0%.
2. The patient slept 5.2 hours out of a total 7.4 hours bedtime
monitored, yielding reduced sleep efficiency of 70%. Latency to
sleep onset was 12.0 minute(s), which was normal.
3. EEGbwas normal. The EKG demonstrated sinus arrthymia. The EMG
depicted REM sleep without atonia in the chin, but no associated
dream enactment behavior (DEB). Certain medications, such as
serotonin medications, can precipitate these findings.

Diagnosis:
Axis I: Sleep related breathing disorder (G47.30)
Axis II: Nocturnal Polysomnogram baseline study, 95810.

Recommendation:
1) For some patients with mild sleep disordered breathing, the
use of a mandibular advancement device may have a role. Also may
consider a follow up CPAP titration trial.
2) The patient should be advised not to drive when sleepy.
3) The patient should avoid long acting sedatives and alcohol
close to bedtime.
4) Suggest exercise and nutrition weight management program.(FOR
BMI >27)
5) For abnormalities noted on EKG, would recommend formal EKG and
holter monitoring.

The patient was referred for sleep testing only. Patient should
return to the referring physician for follow up and management,
including prescribing Nasal CPAP for home use. For formal
consultations with sleep specialist, please call 310-825-2631.

Electronically signed by

Karen Lee, M.D
Diplomate, American Academy of Sleep Medicine
__________________________________________________________________
__________________

The following data based on technologist observation - subject to
physician interpretation
A. GENERAL PARAMETERS MEASURED
Left and Right EOG EKG
Chin EMG Anterior Tibialis EMG
Abdominal Movement Thoracic Chest Movement
Nasal and Buccal Airflow/PTAF Oximetry
EEG (F4-M1, C4-M1, and O2-M1) Snore Sound
Body Position

B. SLEEP SCORING DATA
1. Lights Out: 10:00PM
2. Lights On: 5:24 AM
3. Total sleep time: 311 minutes (5.2 hrs)
4. Total recording time: 443 minutes (7.4 hrs)
5. Sleep Efficiency Index: 70%
6. Wake time: 132 minutes (Normal is equal or less than 20
minutes)
Stage N1: 12 minutes (4% of total sleep time. Normal: 5-15%)
Stage N2: 172 minutes (55% of total sleep time. Normal: 45-80%)
Stage N3: 34 minute(s) (11% of total sleep time. Normal: 0-15%)
Stage R: 93 minutes (30% of total sleep time. Normal: 12-20%)
7. Latency to sleep onset: 12.0 (Normal 10-20 minutes)
8. Wake after sleep onset: 120.0 minutes (Normal is equal or less
than 20 minutes)
9. Latency to REM onset: 144.0 minutes (Normal is equal or
greater than 90 minutes)

C. AROUSAL EVENTS
1. Total number of arousals: 157
2. Arousal index: 30/hr (Normal is less than 10/hr)

D. CARDIAC SUMMARY
Heart Rate Summary
Average heart rate during sleep: 58.0 bpm. Highest during sleep:
82.0 bpm. Highest of awake: 85.0 bpm.

Cardiac Events:
Sinus Tachycardia N/A Bradycardia N/A
Atrial Fibrillation N/A Asystole N/A
Narrow Complex Tachycardia N/A Wide Complex Tachycardia N/A
Other Arrhythmia: The ECG appeared to be predominantly NSR with
occasional possible sinus arrhythmia (sinus rate varies), and
rare possible PVC.

E. MOVEMENT EVENTS
LMs Index
PLMS 51 10/hr
PLMS with Arousal 28 5/hr
F. RESPIRATORY EVENTS
Respiratory Rate: 13 breaths per minute.

The patient did not have Cheyne-Stokes breathing. During baseline
study: Total obstructive apneas: 1. Total central apneas: 1.
Total mixed apneas: 0. Total hypopneas: 7. Total number of
apneas/hypopneas: 9. Total number of RERAs: 48.
Position Supine, Lateral, Prone
Sleep State REM, NREM
Baseline SaO2 Level 96-98%
Supplemental O2 N/A LPM
Minimum O2 Saturation 90.0%
Recorded Sleep Time 5.2 Hours
Apnea-Hypopnea Index (AHI) 2/hr
Apnea Index (AI) 0.4/hr
Hypopnea Index (HI) 1.3/hr
Respiratory Disturbance Index (RDI) 11/hr
AHI on supine position 2/hr
AHI during REM sleep 6/hr
Apnea/Hypopneas Index (AHI): Number of apnea/hypopnea episodes
per hour of sleep (Normal less than 5).
Hypopnea definition (AASM Rule 1B): A decrease in the nasal
pressure signal amplitude of 30% or greater, lasting 10 or more
seconds, with a 4%or greater oxygen desaturation from baseline.
Respiratory Disturbance Index (RDI): Number of apnea, hypopnea,
and respiratory effort related arousal (RERA) episodes per hour
of sleep.

G. OXIMETRY SUMMARY
Percent time and time in minutes for each oxygen saturation range
during sleep:
Oxygen Saturation Range Sleep Time in Minutes Percent of Total
Sleep Time
89%-100% 311 100.0%
81%-88% 0 0.0%
71%-80% 0 0.0%
61%-70% 0 0.0%
Artifact 0 0.0%

[Friendly]

Well, the most recent doctor said he thought CPAP was unlikely to create improvement based on his view of the sleep study numbers, which has prompted this post seeking other's views. He's was on CPAP for four months last year with no improvement, got frustrated and quit, then learned that (1) often four months is not enough and (2) that maybe a different mask and also switching to APAP might yield different results. So just started up again a few weeks ago.

If CPAP improves someone's sleep, that's all that matters.

Everything else is insurance-based mumbo-jumbo.

It don't matter what name you call it.

[Friendly]

Just posted it!

It looks like the data is all from a titration study. You need to post the data from the first study without cpap. That will show what untreated sleep looks like.

[Pugsy]

The study demonstrates sleep disordered breathing with an AHI
of 2/hr, RDI 11/hr, worse during REM sleep. The respiratory
disturbances were associated with mild oxygen desaturations down
to 90.0%. Baseline oxygen level was 96.0%.

Diagnostic sleep study (no cpap used) shows AHI below the usual standard of 5 AHI (5 per hour average) to earn the diagnosis straight away but the "worse during REM" doesn't tell us how much worse which might earn the diagnosis that way.
Especially since the time in REM was higher than normal. Might be a situation where not much is going on in terms of OSA except in REM. Enough to cause symptoms but not meet the official criteria. It's common enough for OSA to be worse in REM...I have it myself.
In REM sleep I have 5 times as many events than I have in the other stages. My OSA is "mild" in non REM sleep but "severe" in REM.

Since this was an in lab sleep study with tech in attendance we assume that the arousals mentioned were probably related to breathing disturbances but that isn't clearly stated.

Given that some of the symptoms causing the sleep study to be done in the first place and the fact that the oxygen levels did drop a bit and something significant apparently happened during REM...I can see where the sleep specialist decided to opt to try cpap as a recommendation. There's more going on than we can see from these notes that might explain things a little better.
Based on the overall AHI and RDI...probably doesn't meet criteria for official diagnosis and probably why the primary care doctor says doesn't have OSA.
But without knowing just how bad things were in REM...we don't know the entire story.

What is also absent is a list of medications that are being taken. Some meds will affect sleep quality along with how we feel during the day and can thus affect arousals which in turn affects how we feel. I take a pain pill that causes insomnia...so I have a choice...sleep poorly from pain or sleep poorly from the insomnia and elevated arousals from the side effects of the pain meds. Talk about damned if you do and damned if you don't kind of thing.

What problem is your friend having that he/she needs help with? I can see both sides here...why the family doctor said no OSA and why the sleep doctor said mild OSA. Maybe he only has OSA bad enough to earn the diagnosis when in REM and since REM is normally 20% of our sleep those numbers get sort of lost in the other 70 to 80 % of the sleep time.

[Friendly]

Thanks for the reply. No medications being taken. Primary issue is difficulty concentrating, "brain fog." Also reporting light sensitivity, sensitivity to motion (as when looking at computer screens).

The number that jumps out at me is the arousal events:

C. AROUSAL EVENTS
1. Total number of arousals: 157
2. Arousal index: 30/hr (Normal is less than 10/hr)

[Pugsy]

Yeah, that arousal index does stand out which is why I mentioned we assume related to breathing because there are other arousals that can happen but they are what we call spontaneous arousals and not brought on by a problem with breathing.

RDI 11/hr,

RDI usually means arousals related to breathing issues plus apnea events.

How they came up with RDI of 11 with the arousal index of 30 doesn't compute unless that 30 includes spontaneous arousals as well as any respiratory related arousals.

CPAP will hopefully help with breathing/respiratory related arousals but not much help for spontaneous arousals.
Spontaneous just means they don't know what caused it. They just know not related to breathing.

What I would want to know is what exactly constitutes "worse in REM" and why...
and was that 30 arousal index a total of spontaneous plus respiratory related.

30 arousals per hour average....going to point to crappy sleep even if it isn't OSA related crappy sleep.
Lots of things out there to mess with sleep quality and thus how we feel during the day.
It would be really nice if cpap could fix the cause of those arousals but if they aren't related to a respiratory issue then not much chance of the crappy sleep being fixed by the machine.
Happens all the time. People expect the machine to fix a problem or get rid of unwanted symptoms that the machine can't fix because the problem isn't related to something the machine can fix.
They have unrealistic expectations as to what the machine can do. CPAP machines can fix crappy sleep with the crappy sleep is from the breathing issues. Doesn't help much when the crappy sleep is caused by something unrelated to breathing/airway issues.

CPAP is worth trying though. And yeah, there are sleep docs who will paint the "let's do cpap and fix all your problems" and they are totally lost when all the problems aren't fixed. Not all sleep docs can think outside the box when things don't work out like they planned.

So....your friend....how many hours of sleep is he/she averaging? Are those hours fragmented with many wake ups?
We now know no meds...so medication side effects taken out of the picture but there are other reasons for not feeling so great.
So we look at sleep itself first...how many hours of sleep? Real sleep and not laying in bed awake...and if many wake ups about how many and why?
Any other health issues going on that might impact things?
He/She has to start thinking outside the box.

[ChicagoGranny]

Excellent comments by Pugsy. This is also of concern:

E. MOVEMENT EVENTS
LMs Index
PLMS 51 10/hr
PLMS with Arousal 28 5/hr

------------------------------------------------------------------------------

Primary issue is difficulty concentrating, "brain fog." Also reporting light sensitivity, sensitivity to motion (as when looking at computer screens).

Those are symptoms of sleep-disordered breathing. They are also symptoms of a lot of other things. At age 31, friend definitely needs to get to the bottom of this. If not treated, these symptoms might get much worse.

[Pugsy]

This is also of concern:

Thanks for mentioning the PLMD stuff. I meant to and got side tracked and forgot. Interesting that the PLMD stuff seemed to improve or be reduced during the titration sleep study. Still not enough of a reduction to suit me and since we never know which came first...hard to know what to do about it but it's part of the "other stuff" that I would want to look at and possibly try something in an effort to think outside the box as to why the sleep is crappy.

Might be why the arousal index is elevated...and RDI isn't so elevated.