Centrals Now?

[StillAnotherGuest]

SAG, Interesting HAS table. My score is 51.

OK, I'm not real big on instructions either, but that'll do for now.

Unfortunately, I didn't start the Prozac until right after the sleep study in 1998, so that won't help comparing the Prozac to Lexapro.

That makes it even better, send that architecture in.

"Moderately severe sleep fragmentation"?

Starting to see a pattern here?

alpha intrusion in sleep

On your list of things to ask, see if that's there in your 2 new studies, too. And to what extent.

"Ars1." What is that?

Arousal.

Ars1 and leg movements, there seemed to be a lot of these.

What a surprise.

Are PSnores just regular snoring?

I don't know that label (or PLMEs, either). The way they have apneas and hypopneas grouped together is a bad feature, too. But based on these contradictions, it doesn't seem to be what we think it should be.

Could shallow breathing be picked up as a CSA?

Technically, yes, there's no consensus on the definition of even apneas (though most folks use greater than 80% flow reduction), or the sensors used to measure them. Personally, I think if you're gonna call someone a CSA patient, there better be a darn lot of zero flow, zero effort events in there.

Just knock me out with a hammer each night--maybe that will work.

Ball peen or sledge?
SAG

[brackstone]

Woah...well I tried reading a lot of this over and over again and most of it seems to be going over my head. I posted in another thread that I've been waking up when I try to fall asleep, because it feels like everything closes up.

Snoredog in there suggested that I might be having a "onset Central". Is that what everyone is talking about in here? If so is can someone give me more of a lamens term interpretation and a possible fix?

I'm assuming with all of the information coming out of this thread that there is no simple fix, if so that's disheartening. I've been having so many problems with my sleep Apena it's pretty depressing

[WearyOne]

Oops, SAG, sorry. For some reason, thought just the number would be okay. Now I realize that doesn't really make any sense. Think I added wrong, too.




1998 Study


I failed to mention this before because I was told it wasn't related, and that may well be the case. I have RLS, but currently do not take anything for it. I was offered Requip by a neurologist, but never took it. Sleep center people said the leg movement thing while you're asleep (PLMD?) isn't related to RLS.

Yes, I'm definitely seeing the pattern. I believe the weight gain since the 1998 study (50 pounds, actually) is a big cause of the OSA, but those arousals and leg movements were there then. Maybe a good thing the interim sleep doc is a neurologist (the other one was a psychiatrist).

Maybe there's no concrete answer, but your statement made me wonder, how many CSA events does one have to have to be considered a CSA patient rather than just someone who has CSA events?

brackstone, yeah, this sleep apnea stuff is depressing. I'm learning that sleep issues are so much more complicated that I ever imagined, unfortunately.

SAG, better use the sledge, a big one. Again, thanks for all the time you're putting into this.


Pam

[Snoredog]

well that 1998 study seems to explain the unexplained arousals seen in the latest study. Looks like someone forgot to hook up your leg movement sensors.

I'm sure you have exhausted the list of medications for it in the last 9 years of dealing with it. Too bad your 2 doctors couldn't treat each other first and come up with a solution

Sometimes you wonder why they can't do a SPECT brain scan while you are asleep find the cause of those movements and zap it with a gamma knife. (pardon my solutions, I fix everything with a BFH )

[WearyOne]

Actually, snoredog, they did hook up the leg things. In fact, in the titration, they had to come in and fix one that came loose. The fact that no leg movements were noted on this year's sleep study and titration have been confusing me. She (assistant) mentioned something about they didn't notate leg movements when they happened at the same time as a respiratory event because I was probably moving my legs to arouse myself because of the respiratory event.

Does that make sense? Even so, I still have a hard time believing I didn't have leg movements outside of repiratory events.

Maybe that hammer SAG is going to use to put me to sleep will hit the section of my brain making my legs move at night!

Pam

[StillAnotherGuest]

OK, great, you got the study. As you note, this is 9 years ago, so a lot of things could and have changed, but this architecture is substantially better than the 2 recent ones, so we would think that the Lexapro is a prime suspect in the sleep disruption. There's much less total wake time within the sleep period. However, there are about 20 awakenings (normally you should have about 2).

Of all those arousals, there's quite a few in REM, and if you blow up the graph, the oxygen waveform looks a little unstable there, so given that OSA tends to be worse in REM, those could be respiratory-oriented, perhaps UARS in nature if the events didn't qualify as apneas or hypopneas.

Overall, a significant increase in arousals occurs after about 3:00 AM, so barring any medication, other underlying medical issue or UARS effect, see how that compares with your sleep studies now, where at 3:00 AM you go to Wake.

Bunch of arousals at sleep onset, again, see how this compares to what you're doing now. This should underscore why it's not those early centrals per se that are the problem in your case.

Oh yeah, the sleep onset-centrals and jerking awake question by brackstone:

Assuming that the obstructive events are properly managed, then the likelihood of (the example presented there) being sleep-onset centrals is fairly high (you'd need PSG to be 100%) and those things are pretty much a normal event.

Jean Krieger in her chapter on Breathing During Sleep in Normal Subjects in Principles and Practice of Sleep Medicine by Meir H. Kryger summarizes the incidence of central apnea/periodic breathing at sleep onset from 40-80% of normal subjects, and lasting from 10-60 minutes. The trigger is hypercapnia, as opposed to the hypocapnia that creates all the cental apnea havoc in CSBD and CSR. Chemosensitivity and apnea threshold also change.

Right, sleep-onset is a very busy time, with a lot of transitional stuff occurring, but this description (awakening with a sudden jerk) sounds a little more like Sleep Starts, also referred to as hypnagogic jerks, sleep-onset myoclonus or hypnic jerks. From the ICSD:

Sleep starts are sudden, brief contractions of the legs, sometimes also involving the arms and head, that occur at sleep onset. Sleep starts usually consist of a single contraction that often affects the body asymmetrically. The jerks may be either spontaneous or induced by stimuli. Sleep starts are sometimes associated with the subjective impression of falling, a sensory flash, or a visual hypnagogic dream or hallucination. A sharp cry may occur.

They're quite common, with a prevalence of about 60-70%.

Starting to get a plan together, Pam, I don't know how well-versed you are about insomnia already, but here's a pretty good State-of-the-Science blurb (Medscape is free):

Insomnia

and begin thinking about Cognitive Behavioral Therapy, a strongly-recommended behavioral approach to insomnia management. Hopefully your new sleep guy will be familiar with this, you may get some good benefit, so familiarize yourself with it for your appointment.

PLMs occur in about 80% of RLS patients, I don't know, I'd call that related.

On the other hand, there's not an awful lot of PLMs there. And PLMs are only a problem if they cause arousal. If those "PLMs" are a result of arousal, then they're not really PLMs (here comes the chicken again). But if you already have RLS...

Do you have the values for sleep efficiency in there (all 3 studies)?
SAG

[WearyOne]

SAG, sleep efficiency from the studies:

1998: 90%
1/2007 diagnostic study: 62.2%
2/2007 titration: 67.1%

The 2007 titration shows arousals unrelated to A/H events after 3 a.m. where I go to Wake. The 2007 PSG study shows a long stretch of being awake after 3 a.m., then when I did get back to sleep, a bunch of arousals A/H and others) that brought me back to Wake.

Last night, for example, it took me two hours to get to sleep. About an hour was fiddling with the mask that was acting up, the other hour, I just couldn't lay still, real restless. Switched to Prozac this morning, btw, and am starting to take all meds in the mornings (was already taking the Synthroid in the a.m.).

On the meds issue, usually on thyroid replacement meds, they want you to be a little on the high end of the range of the FT3 and T4. Don't know if you know much about thyroid stuff, but there is a range to be in, not just a set number. If your numbers are over the top of the range, you're hyperthyroid/below the range, hypothyroid. When I was hyper before thyroid ablation and treatment, I felt similar to last night, only a lot worse (with a lot of other symptoms, too, of course). It's possible that, for me, being in the upper end of the range is too high for me and I just need to be adjusted down a bit. I mean, after all, it is a RANGE. (Although endo doesn't agree or want to try it. )

Cognitive Behavior Therapy. I've heard of this, but not very familiar. I am going to look at your Insomnia link after finishing this post and be very familiar with that and CBT before my next appointment in four weeks. Very informative and helpful quotes you posted from some of your prior posts, too!

I have those leg jerks you mentioned, oftentimes before actually falling asleep. And, weird as this sounds, I'm now having "mouth" jerks sometimes. My mouth and chin jerk. (And In this case, I'm not gasping for air or anything, just a jerk.) And my arms, too.

Yeah, I'd call that 80% connection between RLS and PLMs a biggie, whether they do or not. But then again arousals/PLM's or PLM's/arousals, chickens and eggs, eggs and chickens.

The light is starting to shine through the dark murkiness of this situation.

Pam

[WearyOne]

Bumping back to first page, SAG.

[StillAnotherGuest]

Have you thought about sprinkling some lavender oil around?

Only kidding!

Actually, the powers that be have a summary about non-prescription aids for insomnia, and guess what ain't there:

Oral Nonprescription Treatment for Insomnia: An Evaluation of Products With
Limited Evidence

In your treatment plan, it's important that one of your medical guys takes responsibility for being team leader. I think you've got the idea how all these drugs act in re: sleep quality. You've got maybe 4 things where pharmacological intervention may be employed that will directly affect sleep:

1. Choice of antidepressant
2. Dosage of levothyroxine
3. Choosing to treat RLS
4. Insomnia treatment

Then somebody has to be the go-to guy to make the call when say, thyroid treatment may be at least partly responsible for 65% sleep efficiency.

Then you've got all the things that relate to CBT.

And really look at all aspects of your lifestyle. If you didn't already see the Canada Lung Association Sleep Apnea Handbook, here it is again:

Sleep Apnea Handbook

That's a tactful way of saying the third biggest thing you could do improve your overall situation would be to get to something close to ideal weight. Make lifestyle changes such that you lose a pound a week, or even set a very aggressive goal of 1.5 pounds a week. I know you've got about 2-4 things that may be pulling at your sleep quality now, but looking at that 1998 study, boy, I'm thinking you have a real opportunity to do some major good by attacking that in a big way.
SAG

[Snoredog]

Not really a study:

Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study.

* Hornyak M,
* Voderholzer U,
* Hohagen F,
* Berger M,
* Riemann D.

Department of Psychiatry and Psychotherapy, Albert-Ludwigs-University, Freiburg, Germany.

Periodic limb movements during sleep (PLMS), with or without symptoms of a restless legs syndrome (RLS), may cause sleep disturbances. The pharmacologic treatments of choice are dopaminergic drugs. Their use, however, may be limited due to tolerance development or rebound phenomena. Anecdotal observations have shown that oral magnesium therapy may ameliorate symptoms in patients with moderate RLS. We report on an open clinical and polysomnographic study in 10 patients (mean age 57 +/- 9 years; 6 men, 4 women) suffering from insomnia related to PLMS (n = 4) or mild-to-moderate RLS (n = 6). Magnesium was administered orally at a dose of 12.4 mmol in the evening over a period of 4-6 weeks. Following magnesium treatment, PLMS associated with arousals (PLMS-A) decreased significantly (17 +/- 7 vs 7 +/- 7 events per hour of total sleep time, p < 0.05). PLMS without arousal were also moderately reduced (PLMS per hour of total sleep time 33 +/- 16 vs 21 +/- 23, p = 0.07). Sleep efficiency improved from 75 +/- 12% to 85 +/- 8% (p < 0.01). In the group of patients estimating their sleep and/or symptoms of RLS as improved after therapy (n = 7), the effects of magnesium on PLMS and PLMS-A were even more pronounced. Our study indicates that magnesium treatment may be a useful alternative therapy in patients with mild or moderate RLS-or PLMS-related insomnia. Further investigations regarding the role of magnesium in the pathophysiology of RLS and placebo-controlled studies need to be performed.

PMID: 9703590 [PubMed - indexed for MEDLINE]

[StillAnotherGuest]

Y'know, as an RLS guy myself, I did run that angle, having electolytes tested not only for magnesium, but calcium and potassium as well (there are plenty of things that create leg discomfort other than RLS).

But yeah, an improvement in sleep efficiency from 75% to 85%, especially in that particular range, is huge.

Mirapex, if you're curious, and only occasionally.
SAG

[WearyOne]

Yep, I know--weight is the big issue, really big. Thank you, but no need to be tactful--it's my own fault. Just so hard to do anything about it when you feel so miserable. I could go through a long list of "reasons" why I gained more weight since 1998 when I was already overweight, and why I haven't lost it, but, enough excuses already, right? Gotta start or things will have a hard time getting better.

CBT is also on the list, as well as getting things, pharmacologically, coordinated better. Need to look more closely at the RLS and see what might help there.

Will have a lot to discuss with the new sleep doc at my appointment the end of April.

SAG, thanks for all your help in sorting through all of this. Needed a clear, smart head to help me sort it all out. (Hold off on that hammer for now.)

Oh, yeah, that lavender oil sounds nice, too!

Pam

[WearyOne]

snoredog, thanks for the RLS/PLM/magnesium info. I already take a higher-that-average amount of magnesium each day for another issue, but it might not be the same amount, and I usally take it AT bedtime rather than in the evening (which I would assume would be earlier than bedtime).

Will look into that (and mirapex, too, SAG).

pam