What do you talk about with your sleep Dr?

[Simbot]

Thanks. I've been using Lunesta in a similar fashion as you describe for many months. I've been off of it for a couple of months since I stopped CPAP and switched to the oral appliance. I've had to start using again recently now that I'm trying CPAP again. I don't have any problem with pills, I'll use anything that works.

I can't keep trying CPAP forever, at some point it either has to start working for me, or I have to give up on it. I don't know how to tell if I'm at that point or not. I've been at this for a year now. But I'm not as knowledgeable as many of you are, so I'm trying to learn as much as I can and give it my best effort this time. I really don't know what else to do at this point.

I tried increasing my pressure from 10 to 11 last night, AHI was down a little, but I had some leak issues that woke me up a couple of times. At 10 I don't have any leaks, but AHI is still too high, ranges from 8-12 on any given night.

All of this reading and thinking about sleep, stresses me out and makes me sleep worse. It's better for me if I don't think about it, I was able to do that for a while with the appliance. I don't want to spend much time here, but I need help.

[chunkyfrog]

As long as the discussion is about insomnia and drugs, here's a fairly recent thread:
viewtopic.php?f=1&t=77398&p=705287&hili ... or#p705287

[49er]

[*]A primarily drug based approach---i.e. offer you a prescription for Ambien or some other sleeping pill.
[*]A primarily CBT based approach---i.e. start with good sleep hygiene and a sleep log. If the problem persists, then perhaps moving on towards a sleep restricted schedule for a while.
[*]A mixed approach---i.e. giving you a sleeping pill prescription while stressing the need to pay close attention to your sleep hygiene.l[/list]

The problem I have with this is that it is one size fits all.

In my case, I literally have trouble staying awake after dinner to the point where I feel drugged. Yesterday, in a failed attempt to stay awake, I was standing in the kitchen and almost hit my head against the refrigerator as I caught myself starting to fall down.

Anyway, I fall sleep prematurely which greatly messes up my sleep cycle. But yet, many doctors would ignore this issue and tell me to see a cbt therapist who would suggest sleep restriction. Yeah right, I can't even stay awake after dinner and you're going to tell me to stay awake until midnight? I don't think so.

By the way, sleep doctor number two feels that once I start sleeping on the machine (which is another post), this will resolve. So I have got to find a way solve this problem be it changing my diet or simply not eating until it is close to bedtime and consume a light snack.

Sorry RobySue, I don't mean to sound like I am ranting against you. I just get tired of this one size fits all boiler plate medicine practices.

49er

[robysue]

[*]A primarily drug based approach---i.e. offer you a prescription for Ambien or some other sleeping pill.
[*]A primarily CBT based approach---i.e. start with good sleep hygiene and a sleep log. If the problem persists, then perhaps moving on towards a sleep restricted schedule for a while.
[*]A mixed approach---i.e. giving you a sleeping pill prescription while stressing the need to pay close attention to your sleep hygiene.l[/list]

The problem I have with this is that it is one size fits all.

Giving a person a choice of three viable alternative treatments to insomnia hardly seems like a "one size fits all" approacho to me.

Ah, but you probably mean "CBT is one size fits all." As with anything else, there are good andbad CBT therapists and good and bad approaches to CBT for Insomnia.

A quality CBT person will NOT use a "one size fits all" approach. S/he will listen to the person/patient s/he is working with and make the appropriate adaptions to the proposed CBT. A less talented/knowledgeable/competent one will indeed gravitate to a "one size fits all" approach. And a less talented CBT therapist may very well push "sleep restriction" too early and too often on their insomnia patients without listening enough to the patient to figure out that such an approach is not likely to work for their patients.

But drug therapies are also typically a "one size fits all" approach---how often does a doc bother to adjust the dose of a particular medication? Why is it just assumed that someone my size (110 lbs) and someone the size of my hubby (175 lbs) and someone who is really large (say 220 lbs) should all be put on the same dose of a typical medication? Yes, some medications, including some sleeping pills, are available in multiple dose sizes. But for the most part there's a standard beginning dose that is the one most commonly prescribed---regardless of the patient's size and patient's tendency to be sensitive to all/most medication.

In my case, I literally have trouble staying awake after dinner to the point where I feel drugged. Yesterday, in a failed attempt to stay awake, I was standing in the kitchen and almost hit my head against the refrigerator as I caught myself starting to fall down.

Anyway, I fall sleep prematurely which greatly messes up my sleep cycle. But yet, many doctors would ignore this issue and tell me to see a cbt therapist who would suggest sleep restriction. Yeah right, I can't even stay awake after dinner and you're going to tell me to stay awake until midnight? I don't think so.

A sleep restricted schedule for insomnia is usually NOT the first thing that a CBT therapist is going to suggest. It's a pretty drastic approach and it's not for everyone. There are literally a whole bunch of things that can be tried before or instead of a sleep restricted schedule.

You've got a very different issue with your insomnia than I had with mine: You fall asleep prematurely (and inappropriately) rather than putting bedtime off until 3:00 or 4:00 AM because you can't stand the thought of going to bed only to lie there and not sleep for what seems like hours on end. Indeed, from the sound of your daytime/early evening symptoms, it sounds like there's something more than simple insomnia going on: A circadian rhythm disorder perhaps. Or some narcolepsy. Or just some extreme OSA symptoms which sleeping with the machine should resolve in time. But whatever the root of your problem is, all the "daytime sleeping" does, as you say, greatly messes with your overall sleep cycles. And, if I recall correctly from your other posts, that results in your inability to stay asleep during the night and/or causes you to wake up way too early in the morning, but you can't manage to get back to sleep. And so in your case, a sleep restricted schedule that focuses on trying to make you stay up significantly later during the evening is not going to work all that well simply because it asks you to do what seems to be impossible.

But in my case a sleep restricted schedule made a whole lot of sense: Staying up to the wee hours of the morning is not usually a problem with people who have severe bedtime onset insomnia like I did. My bedtime insomnia was being fed by many things, but one of its feeders was that I was getting up very irregularly and often very, very late---as in unacceptably late for my lifestyle. And every time I slept in until 10AM, 11AM, or noon, it aggravated the problem with not getting sleepy enough to get to bed in a timely fashion the next night. And hence, the restriction in my case came primarily from regularizing my wake up time. And that's why it was important for my PA to make me decide when I would get up seven days a week. Had I been simply told "Get up at 6:00AM every day, even weekends" I would have failed miserably at following the instructions because the idea of getting up at 6:00 AM every day seems impossible to me.

By the way, sleep doctor number two feels that once I start sleeping on the machine (which is another post), this will resolve. So I have got to find a way solve this problem be it changing my diet or simply not eating until it is close to bedtime and consume a light snack.

Changing your diet and consciously making the decision to NOT eat too close to bedtime or opt for a very light snack are two quality examples of "CBT for Insomnia" suggestions.[/i] And I hope they help you solve some of your problems.

I also hope that Sleep Doc #2 is correct and that your problems start to resolve once you start sleeping on the machine. But DeltaDave's mantra of YOU CAN'T FIX BAD SLEEP WITH A CPAP MACHINE!!! has also popped into my mind here. And so I ask:

How are you going to start sleeping with a six foot hose attached to your nose if you already have problems with sleeping in the first place?

Indeed, the expectation that CPAP was the "answer" to my sleep problems was the "cookie-cutter" "one-size-fits all boiler plate solution" problem that I initially ran into with my own encounters with Sleep Doc #1: Initially both he and his PA believed that if I just would start sleeping with the machine that all my sleep problems would resolve themselves. My one and only consultation with Sleep Doc #1 occurred before I started CPAP and after I expressed my concerns about potential adjustment issues and my desire for a full efficacy data machine, he said to me: "Don't worry about that. You'll start feeling better in about two weeks after you start CPAP." Fortunately the PA who he passed me off to for the follow up appointments came to realize after about a month or two of my being 100% compliant with "sleeping with the machine" while experiencing a corresponding and hideously severe deterioration in my insomnia and daytime functioning, that "sleeping with the machine" was not going to make me feel any better all by itself. And so she started pushing me to do something about the insomnia fairly early while also making appropriate changes in my PAP therapy.

And because you are apparently having some troubles figuring out how to sleep with a six foot hose attached to your nose, I have to ask: What kinds of approaches to dealing with your insomnia ARE you willing to try?

And, in an effort to understand more about your particular insomnia problems, I'd like to know:

What time do you WANT or NEED to get up in the morning on all seven days of the week?

In an ideal situation, WHEN would you like your regular bedtime to be? 8:00pm? 9:00pm? 10pm? 11pm? Midnight? Please keep in mind I'm wanting you to tell me what YOU WANT your bedtime to be for all seven days a week.

Can you describe your current typical bedtime/wake up times for me? On an average night, when do you through in the towel and go to bed because you just can't stay awake anymore? When do you typically force yourself to get up in the morning?

How much actual sleep do you get between the time you go to bed and the time you get up for the morning? I'm not asking how long are you in bed---I'm asking how long are you actually asleep during the time you are in bed. The idea here is to figure out what your typical estimated sleep efficiency is on a nightly basis. If you are asleep for close to 90% of the time you are in bed, then sleep maintenance insomnia is probably not your problem.

Do you take naps (intentional or unintentional) during the daytime? How much time are you asleep during the naps? How close to your DESIRED bedtime is your last intentional nap?

And finally note that a quality CBT therapist would ask you these questions before designing any CBT program involving sleep restriction or artificially delaying bedtime.

[49er]

Hi RobySue,

Thanks for your usual great responses.

As an FYI, in my mind, I think of CBT and drugs as one option because it is always linked together as a solution for insomnia. But your points are well taken about the meds.

Regarding sleep restriction therapy, I have never seen any site on CBT for insomnia in which SRT is not highlighted. So I am glad to hear that SRT isn't necessarily part of CBT.

To answer your question about issues in sleeping on the CPAP, thanks to Dr. Pugsy:), I feel I am very close to being able to sleep a good block on the machine. Two nights in a row, I was able to initially sleep three hours on the machine in spite of having poor sleep hygiene days.

One day, I had taken naps because I simply was exhausted from lack of sleep due to falling sleep prematurely. On the other day, I fell asleep prematurely but it didn't prevent that initial block of sleep on the cpap.

Anyway, because I expressed optimism to my sleep doctor about this, that is why he responded the way he did about the cpap solving the problem.

You've got a very different issue with your insomnia than I had with mine: You fall asleep prematurely (and inappropriately) rather than putting bedtime off until 3:00 or 4:00 AM because you can't stand the thought of going to bed only to lie there and not sleep for what seems like hours on end. Indeed, from the sound of your daytime/early evening symptoms, it sounds like there's something more than simple insomnia going on: A circadian rhythm disorder perhaps. Or some narcolepsy.

I have wondered whether I have advanced phase disorder and as a result, I bought a light therapy lamp which I have used sporadically. I might try it again.

And, if I recall correctly from your other posts, that results in your inability to stay asleep during the night and/or causes you to wake up way too early in the morning, but you can't manage to get back to sleep

.

Got back to sleep on Sunday night although I took off the mask because I just assumed I had only slept one hour as in the past and saw no point in doing the hour at a time routine which greatly made things worse. Now that I see things have improved, i am encouraged to keep trying.

Monday night, I did have trouble getting back to sleep but eventually did on the machine. Even had a crazy dream I had fallen asleep prematurely so that might have messed things up.

sleep restricted schedule made a whole lot of sense:[/i] Staying up to the wee hours of the morning is not usually a problem with people who have severe bedtime onset insomnia like I did. My bedtime insomnia was being fed by many things, but one of its feeders was that I was getting up very irregularly and often very, very late---as in unacceptably late for my lifestyle. And every time I slept in until 10AM, 11AM, or noon, it aggravated the problem with not getting sleepy enough to get to bed in a timely fashion the next night. And hence, the restriction in my case came primarily from regularizing my wake up time. And that's why it was important for my PA to make me decide when I would get up seven days a week. Had I been simply told "Get up at 6:00AM every day, even weekends" I would have failed miserably at following the instructions because the idea of getting up at 6:00 AM every day seems impossible to me.

Just to show how different we are, I would love to be able to sleep until 6am. Anyway, I can see why SRT worked for you.

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I also hope that Sleep Doc #2 is correct and that your problems start to resolve [i]once you start sleeping on the machine[/i].   But DeltaDave's mantra of [b]YOU CAN'T FIX BAD SLEEP WITH A CPAP MACHINE!!![/b] has also popped into my mind here. 

What if the bad sleep is due to sleep apnea? I think in my situation, there is more than just apnea but I honestly think that is a big part of the equation.

I would also add that you can't fix bad sleep with a cpap machine that isn't set correctly. I honestly thought that my pressure range was correct since I had a low AHI but after corresponding with Pugsy, I realized I was wrong.

Indeed, the expectation that CPAP was the "answer" to my sleep problems was the "cookie-cutter" "one-size-fits all boiler plate solution" problem that I initially ran into with my own encounters with Sleep Doc #1: Initially both he and his PA believed that if I just would start sleeping with the machine that all my sleep problems would resolve themselves. My one and only consultation with Sleep Doc #1 occurred before I started CPAP and after I expressed my concerns about potential adjustment issues and my desire for a full efficacy data machine, he said to me: "Don't worry about that. You'll start feeling better in about two weeks after you start CPAP." Fortunately the PA who he passed me off to for the follow up appointments came to realize after about a month or two of my being 100% compliant with "sleeping with the machine" while experiencing a corresponding and hideously severe deterioration in my insomnia and daytime functioning, that "sleeping with the machine" was not going to make me feel any better all by itself. And so she started pushing me to do something about the insomnia fairly early while also making appropriate changes in my PAP therapy.

The way you were treated wasn't good either and it is great the PA realized the mistakes.

I experienced the other side of the coin with sleep doctor number one. She just wanted to throw meds at my problem and never looked at my card data when i asked her to make sure the pressures were right.

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What time do you WANT or NEED to get up in the morning on all seven days of the week?

During the work week, 5am would work. To be honest, if I slept until 6am on the weekends, in my opinion, that would not hurt my sleep cycle.

In an ideal situation, WHEN would you like your regular bedtime to be? 8:00pm? 9:00pm? 10pm? 11pm? Midnight? Please keep in mind I'm wanting you to tell me what YOU WANT your bedtime to be for all seven days a week.

Well, I don't know how much sleep I need But let's go with 6 since that would have me going to bed at 11pm. That way I could stay up to watch my favorite TV shows like sporting events

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Can you describe your current typical bedtime/wake up times for me? On an average night, when do you through in the towel and go to bed because you just can't stay awake anymore?   When do you typically force yourself to get up in the morning?

My goal is always to go to bed at 9pm. That is the thing, I wake up around 2am and don't have to force myself to get up

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How much actual [b]sleep[/b] do you get between the time you go to bed and the time you get up for the morning? [/i]  I'm not asking how long are you in bed---I'm asking how long are you actually asleep during the time you are in bed.   The idea here is to figure out what your typical [i]estimated sleep efficiency[/i] is on a nightly basis.   If you are asleep for close to 90% of the time you are in bed, then sleep maintenance insomnia is probably not your problem.

I have no idea.

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Do you take naps (intentional or unintentional) during the daytime?  How much time are you asleep during the naps?  How close to your DESIRED bedtime is your last intentional nap?[/i]

Yup and actually, it has been my experience that if I take short naps (15 minutes) and take them before 2pm that it does not interfere with sleep.

By the way, the reason I am optimistic about the apap settings was I thought when I put my mask on for a nap on Sunday, I would only sleep about 15 minutes. I slept an hour.

49er

[ems]

49er... it's obvious that although you are still experiencing problems, you are well on your way to conquering your insomnia and CPAP issues.

[AHI15]

Pink Floyd seems appropriate.

We don't need no consultation.
We don't need no leak control.
No consultation with the patient.
Pappers leave those knobs alone.
Hey! pappers, leave those knobs alone.
All in all, you're just another brick out the door.

https://www.youtube.com/watch?v=YR5ApYxkU-U

Make the office visit, get rid of the patient, ring the register. NEXT!!!

OMG, you deserve an award for that!

[snuginarug]

I have been on cpap for over two years. My first doctor was useless. Canned spiel, refusal to look at data, no helpful advice. So finally I switched to a new one. To be succinct, he spent a long period of time listening to my situation and habits, then ordered a pressure change and explained it to me. That is pretty much what a good doctor should do... listen carefully and then explain his or her suggested treatment. I have a simple case, though. No pills, no CBT, none of that. Just trying to optimize cpap therapy.

To be specific, what we talked about was 1) mask fit, leaks and comfort 2) toleration of pressure 3) the exact nature of my mask horrors 4) preferred sleep position 5) history of sleep problems 6) results of my first sleep study 7) what type of improvements I experienced upon starting cpap (he was especially interested in that). I think that is all he asked about. Very thorough and attentive.

I encourage you to search for a good doctor. If your doctor is happy with you not feeling good, time for a new doctor. Don't give up on cpap. It is the best treatment for OSA.

[Xney]

For the past 6 months, it's me talking about how PAP therapy is only working up to about 50% despite good numbers, them telling me how it must be because I went to sleep 2 hours later than normal a few times in a week or some other BS. Time to try a different place

They were good before this point, but they've not really had any thinking going on for a year.

[zoocrewphoto]

I've had a really good experience with my sleep doctor It probably helps that he has sleep apnea himself, so he really does understand it from a patient's perspective.

At the first appointment, he went through my graphs and explained them. He answered questions, and explained what he wanted my therapy to be. I had not joined this forum yet, so I didn't know very much yet. I did feel great for that one day after my sleep study, so I was excited to get started. He did tell me at that time that he had sleep apnea too, and he was prescribing a Resmed machine because he liked their software. So, once I did join the forum the next week, I was excited to know I had a great machine with full data and that my doctor wanted to actually see the data.

I had my followup appointment 6 weeks later. He was really pleased with my therapy. The prescribed range was doing well. My data showed that my ahi was awesome (most days below 2). And he asked how I felt (much better). He did ask if I had questions, and I had some. He was surprised with my printouts, but pleased and asked where I had gotten the software. He also showed his receptionist, who also has sleep apnea.

Shortly after that, I let me mom use my machine for half of two nights, first at her prescription of straight 10 and then 10-13 to see what the machine wanted to do. The first night at 10 had a good ahi, but really long apneas (one was 62 seconds). So she called my doctor's office and asked for an appointment. She disliked her old doctor. I went with her to the appointment. He was totally cool with me using my machine to get some data for her (she was denied for a new sleep study as the last one was 2 years ago). He even shook my hand for getting my mom in there for better treatment. He asked her questions about her previous treatment, did she feel any improvement (no). He looked at her current machine and mask (she just got a new mask, like mine). He looked at the reports from my machine and the sleep study summary from 2 years ago (thankfully, her pulmanologist had a complete copy). He decided to prescribe the S9 Autoset at 10-15. Her followup appointment will be today (Friday). Looking at the data, my guess is that he will probably adjust her prescription a little upward. She is doing better, and actually feels better too, something she hasn't noticed in years with the old prescription. But I can see that her machine wants to go higher than 15. I'm curious though as he leak graphs looks very different from mine. They rarely go above the threshold line, but she does have a lot more leak than me. I have very low leak, sometimes a flat line at zero. Her data doesn't like as straight forward as mine does.

In the 3 appointments I have been to, he has spent about 20 -30 minutes with me (or my mom). He values real data from the machines and is willing to make adjustments to make sure that treatment is actually working. And I like that he can give real advice in getting used to the machine.

If anybody needs a new sleep doctor in the Seattle area, I will be happy to recommend him. He's in Federal Way.

[pharm30]

Appts last about 3 min. Assistant takes my BP and has me fill out questionaire. Dr (pulmonologist) looks at it, adds up #'s, compares it to last appt.
Better or same - great, see you in 6 months.

[49er]

Appts last about 3 min. Assistant takes my BP and has me fill out questionaire. Dr (pulmonologist) looks at it, adds up #'s, compares it to last appt.
Better or same - great, see you in 6 months.

Sheesh and I thought my last 15 minute appointment with my sleep doctor fell short.

I feel for you big time.

49er

[KEQ5]

Appts last about 3 min. Assistant takes my BP and has me fill out questionaire. Dr (pulmonologist) looks at it, adds up #'s, compares it to last appt.
Better or same - great, see you in 6 months.

If I was getting visits that short / abrupt, then I'd only go in when things changed or when required to by insurance.

[themonk]

MIne is usually a lot of 'hmmm, I don't know why that is'. From a supposed 'Diplomate'.

[CentralScrutinizer]

I like my Dr... well she's not really a Dr, but rather a Physicians Assistant I think. Generally speaking, I don't have any real issues related to CPAP, but do have to go see them once a year to keep insurance happy. We usually talk about what new masks might be out there, or something... Either way, she's always been quite helpful really, especially back when I was having trouble getting back to sleep at night if I did wake up, she helped me obtain AutoPAP, which was REALLY a great improvement over standard CPAP.