Sleep apnea + sleep maintenance insomnia

[speppers]

Hello dear friends!

Last time I posted here, I received incredibly helpful responses. As my sleep physician has been dramatically less-than-helpful over the past two months, I thought I would return to pick your brains. As you may have guessed from my title, I was diagnosed with both "mild" sleep apnea (I don't think it was mild) and sleep maintenance insomnia. I use the Resmed S9 every single night, 100% of the time that I am sleeping.

My main issue, at present, is the following: when I have deep sleep, I have more apneas; however, I frequently have lighter sleep (and fewer apneas). What this means is that no matter what, my sleep is fragmented, whether by apneas or interruptions caused by insomnia. I feel incredibly frustrated. My sleep doctor says that he can only work on one problem at a time (???), which I can somewhat understand because there is no specific treatment for sleep maintenance insomnia. My sleep hygiene is perfect. I have been told to take melatonin, even though melatonin only helps with latency and not maintenance.

I can't remember the last time that I got a good night's sleep. I'm sure you can imagine - we are all in the same boat. Anyway, I was hoping, first, to see if anyone else has similar issues to mine (sleep apnea and sleep maintenance insomnia simultaneously). Second, I thought I would show you some Sleepyhead graphs. My prescribed pressure was 6-12, but of course my DME set it to 4-16 for some unknown reason. Anyway, I used 4-16 for a good two months before my sleep doctor informed me that that wasn't my prescribed pressure, and changed it to 6-12. I used 6-12 for two weeks before realizing that my maximum pressure was hitting the ceiling, so I changed the max pressure to 16. I found that the 6 was not close enough to my 95% pressure, either, so I changed it to 7. Thus, my pressure settings are now at 7-16. I have been on this pressure for just a couple of days, and have been taking 2.5mg of melatonin for the past couple of days. (I started with 5mg melatonin, as 'prescribed', and it made me so groggy that I could get nothing done on the following day.)

Here are my graphs for the past few days:









The nights with lower AHI's have been the nights that I have simply not gone into deep enough sleep.

Thank you, in advance, for your help.

[speppers]

Oops - perhaps the following graphs (same days) would be more helpful with regard to pressure:

[robysue]

speppers,

Welcome to the forum

First of all, even the worse of your nights is technically quite acceptable in terms of efficacy of therapy----a treated AHI less than 5 is the usual goal. Of course, you say you were diagnoised with "mild" sleep apnea. Do you know what your untreated AHI was?

Next: You write

I was diagnosed with both "mild" sleep apnea (I don't think it was mild) and sleep maintenance insomnia. I use the Resmed S9 every single night, 100% of the time that I am sleeping.

My main issue, at present, is the following: when I have deep sleep, I have more apneas; however, I frequently have lighter sleep (and fewer apneas). What this means is that no matter what, my sleep is fragmented, whether by apneas or interruptions caused by insomnia. I feel incredibly frustrated. My sleep doctor says that he can only work on one problem at a time (???), which I can somewhat understand because there is no specific treatment for sleep maintenance insomnia. My sleep hygiene is perfect. I have been told to take melatonin, even though melatonin only helps with latency and not maintenance.

We need more information on the insomnia end of things.

You say you have been diagnosed with sleep maintenance insomnia. How does this manifest itself? And what lead to this diagnosis? Are you remembering multiple wakes on many nights? (How many wakes? And how long are they? How many nights per week do you remember multiple wakes?) Or was this based on a sleep study that showed an excessive number of spontaneous arousals and wakes that were NOT related to the sleep apnea.

I ask because there's not a whole lot of obvious evidence of sleep maintenance insomnia in the data you posted. I'm NOT saying that you don't have a problem with sleep maintenance insomnia; rather what I'm saying is you are not waking up and turning the machine off and on because you're taking bathroom breaks or simply out of the need for getting rid of excess air in the stomach or other comfort issues. There's a bit of variability in the flow rate that might indicate some restlessness, but there's just as much of that on the night with an AHI = 2.45 as the other nights.

My sleep hygiene is perfect.

Can you describe your sleep hygiene? As in:

Consistent bedtime? On the nights you posted, bedtime ranges from as early as 11:05 pm to as late as 1:06 am. A lack of consistent bedtime can feed sleep maintenance insomnia. (But it's also important to NOT go to bed when you are NOT sleepy.)

Latency to sleep? How long do you lie in bed at the start of the night before falling asleep the first time?

Consistent wake up time? Your wake times do seem a bit more consistent than the bedtimes: Earliest wake time is 7:40 and the latest is 8:45. But establishing a fixed wake up time would probably be useful. And a fixed wake up time needs to be a wake up time for all seven days of the week.

Also, what is the first thing you do when you realize that you are awake in the middle of the night?

And finally: How long does it usually take you to get back to sleep once you've woken up in the middle of the night?

I can't remember the last time that I got a good night's sleep. I'm sure you can imagine - we are all in the same boat. Anyway, I was hoping, first, to see if anyone else has similar issues to mine (sleep apnea and sleep maintenance insomnia simultaneously).

I have had serious problems with both bedtime onset and sleep maintenance insomnia ever since starting PAP therapy back in 2010. I also have a circadian rhythm problem that adds complexity to my fragile sleep. The insomnia problems wax and wane. Much of the time I can keep the insomnia under control, but periodically it breaks out of control. And when that happens, it can take me months of "work" to bring it back under control.

A year ago both the bedtime onset and sleep maintenance insomnia were really bad: Bad enough for my sleep doc to tell me that it was worth taking Ambien every night for a while, even though the Ambien was only going to work for the first half of the night. It took a good 6 months before things started to turn around this time: Things had to stabilize before they could start to get better, but ever since about March things have been getting better and I'm now feeling like the sleep is less interrupted (except when traveling).

[speppers]

Robysue, thank you so much for your response. To answer your questions:

• 1. My untreated overall AHI was 6.7. I do not believe that this was accurate, as I had very little deep sleep and very little REM sleep. During the REM sleep that I did have, my AHI was 19. In supine position, my AHI was 8.2. Also, during the sleep study, all apneas were hypopneas, actually.
  
  2. I know that an AHI below 5 is considered acceptable; however, I only bring up my AHI because I feel UTTERLY EXHAUSTED. Like, I feel like I'm going to die, I'm so tired. My sleep physician is of the opinion that my AHI should be below 1. I don't know what to think of that, since he has given me very little advice overall, but just decided to mention it.
  
  3. Sleep maintenance insomnia was diagnosed on the basis of spontaneous non-respiratory arousals during my sleep study. While I had 26 respiratory arousals, I had 71 spontaneous arousals. These arousals were in the form of alpha wave intrusions. I should add that I have suffered from a pretty severe anxiety disorder in the past, though I am thankfully in remission now. I have no doubt that they are related.
  
  4. Very rarely do I actually remember wakes. If I really think about it, there are times that I do wake up at night and then forget about it in the morning, only to remember it later in the day. "Oh yeah, I woke up when I heard that sound" - that sort of hting.
  
  5. You're right - I almost never wake up and turn off the machine (this has happened 1-2 times in total), and I very rarely get up to go to the bathroom (thank goodness). My main issue is tossing and turning, and then waking up in the morning and feeling like a zombie.
  
  6. Once again, I must correct myself. Up until about 3-4 weeks ago, my sleep hygiene was perfect, including consistent bedtime and wake-up time. At present, it is perfect *aside* from that - I do not ever go into bed unless I am ready to sleep, I have no electronics in the bedroom, etc. Thus, it takes me about 10 minutes to fall asleep, if that. I thankfully do not have a latency problem. I very rarely realize I'm awake at night, so I assume that I fall back asleep pretty immediately. There have been times that I have been fully awakened - during those rare times, it takes me some time to fall back asleep, but always less than 20 minutes. If it had taken more than 20, I would have gotten out of bed. I did CBT-I for six months prior, including sleep restriction. Unfortunately, I was never able to achieve a sleep efficiency above 85%. The reason for my inconsistent sleep and wake-up times lately is twofold: one, my job has been very strange lately and I have been working odd hours trying to meet deadlines; and two, I've become frustrated with my sleep situation and am trying to sleep later in the morning. As late as possible. Of course, 99% of the time, my brain wakes up at around 7:30am and does not allow me to fall back asleep.

I'm so sorry to hear about your sleep difficulties. I can understand all too well how frustrating it can be. Did Ambien cause any issues with your PAP therapy - did you experience an increased AHI? I actually find your story encouraging. I have only been PAP-ing for about 2.5 months.

Once again, thank you so much for your response. I could not be more grateful.

[kteague]

Please do respond to Robysue's inquiry as to the specifics of your sleep issues. Sometimes there can be clues in the smallest of details.

For years I slipped in and out of sleep every few minutes. I once described it like this... My pursuit of sleep reminds me of a greased pig chase at the county fair - easy to grab but nearly impossible to hold on to. It's particularly frustrating when there is nothing identifiable to work on. Have you already ruled out medication side effect and thyroid dysfunction? Something Robysue said stuck out to me, about giving the brain a chance to stabilize. Well put. When symptoms persist despite our best efforts and it seems like the brain needs to be retrained to sleep, giving it a chance to heal and establish a new normal seems logical to me.

For me, once I got past optimizing and adjusting to my CPAP treatment, I was left with jumpy legs from RLS/PLMD to address as well as a brain that seemed to have habituated to extremely fractured sleep. Even once my legs were reasonably controlled by using a TENS Unit, that could not stop what PLMD does in my brain - that has been a long-fought battle as it is extremely disruptive to sleep. Robysue mentioned your flow rate maybe indicating restlessness - did your sleep studies say anything about limb movements being a problem or have you been told your legs move a lot in your sleep? Not that my problem is necessarily your problem, just searching for clues.

Good luck going forward and finding better sleep.

EDIT: I see you've replied to Robysue. Will read that.

[kteague]

Ok. Read your post. I've seen discussions on here about alpha wave intrusions, will leave that to someone knowledgeable to comment on. Still curious if limb movements could be an issue for you.

[speppers]

Thanks for your response, kteague. I totally understand letting one's brain adjust, but from a "sick" person's perspective, this sucks, you know? I just want something to fix this.

There was some concern that I was taking Cipralex at night and it may be causing the fragmentation, so I moved it to the morning about two weeks ago. My thyroid function is normal (assessed about a week ago). The sleep study showed no limb movements. I believe the flow limitation is less PLMD and more tossing-and-turning, though honestly, I am not entirely ruling out PLMD because I am fairly certain that my sleep study only showed a mitigated version of my issues.

Again, appreciate your response. Nice to have a support system here.

EDIT: By the way, guys - does anyone know if I should be concerned that increasing my minimum pressure to 7 might be increasing central apneas?

[Luthie2006]

Hello, and I will try my "hand" too. I also have sleep maintenance insomnia. No problem falling asleep. I always 100% of the time wake up for 1-2 bathroom breaks no matter what time I stop drinking liquids at night, even 6 pm. Still up at 1030 pm or so (after going to be around 930) for m y first bathroom break with CPAP. And I have not slept through any nights since being on CPAP a few months ago. However, my sleep clinician (who is wonderful) said, "Look at it this way, you slept the same lousy before CPAP, and you still sleep lousy, but the difference is at least you are breathing and not stopping your brain of oxygen or heart." It's just something that helps me.
Also, a few of the wonderful members on here suggested to me, to turn my clock around. I have to get up very early each morning (5:00 am) and when I did have a bathroom break, I would look at the time and say to myself consciously, "Luthie, you only have 1 hour left to sleep, darn it." Now when I get up for my 1-2 bathroom breaks, I don't look at the clock because it unenables me to get into any kind of decent sleep. These are just a few tricks I learned from here. I am hoping for you that these suggestions just help 1/56th for you. It's not a solution by any means, but it's a good thing to think the next time you have a bad night's sleep (which is every night for me too). But at least the CPAP is helping you not lose oxygen to your brain/heart other organs even if you do have a horrible night's sleep. I hope this helps a little bit.

[speppers]

"Look at it this way, you slept the same lousy before CPAP, and you still sleep lousy, but the difference is at least you are breathing and not stopping your brain of oxygen or heart."

I really like this quote. Thank you so much. I will try to keep this in mind. This is a difficult problem to solve, for sure - so sorry you're going through the same thing.

[kteague]

...I believe the flow limitation is less PLMD and more tossing-and-turning, though honestly, I am not entirely ruling out PLMD because I am fairly certain that my sleep study only showed a mitigated version of my issues...

No doubt you are right about that on so many levels. FYI, there is a phenomenon called "masking" where either OSA can obscure PLMD or on the flip side PLMD can obscure OSA. Just a little light reading if you're so inclined...

http://www.ncbi.nlm.nih.gov/pubmed/22854768
http://www.ncbi.nlm.nih.gov/pubmed/14572125
http://www.ncbi.nlm.nih.gov/pubmed/23818327

[speppers]

Goodness. Well, I wouldn't be surprised if I had limb movements in deeper sleep, when treated for OSA, given that I am almost always just borderline anemic even when I take iron supplements. I abhor the idea of doing another sleep study, though. And I suspect that the limb movements would resolve if they were iron-related. Wish there was an easier way to figure this all out! Thanks for the links kteague!

[Setj]

have been taking 2.5mg of melatonin for the past couple of days. (I started with 5mg melatonin, as 'prescribed', and it made me so groggy that I could get nothing done on the following day.)

Speppers, I only want to comment on melatonin, what I learned here from others and what I put into practice.

Until recently there were not good studies on the dosage level. The dosages that are widely available range from one mg to 20 mg with 3 to 5 mg being the most popular pill size.

Recent studies have shown that the doses generally available are much too high. To cut to the chase, based on recent studies the best dosage levels are though to be under one mg.

The other problem is with timing. If you take, say, 500 mcg (one-half mg) at bedtime it will be absorbed and become active quickly. You will have too high dosage for awhile and then the amount in your system will dissipate and you may have too low dosage for the second half of the night.

My problem has always been sleep maintenance. So I bought 200 mcg (one-fifth mg) melatonin tablets from Puritan's Pride. I generally go to bed at 11 and fall asleep quickly without taking anything. I sleep well until 3 when I awaken. Then I take 200 mcg melatonin. I usually fall asleep quickly and sleep until 6.

Some nights I awaken at 1 or 2. Then I will take 2 x 200 mcg and this typically gives me sleep until 6.

Last night I awoke at 3. Because I will be traveling late tonight, I wanted to sleep a little late this morning. So I took 2 x 200 mcg and was able to sleep until 7:30. CPAP said I used it for 9 hours and I felt great this morning upon arising.

So my advice to you is to experiment with one or two 200 mcg tablets of melatonin.

I am assuming you are 50+ and your body no longer produces a normal amount of melatonin. Except for shiftwork changes and jetlag, young people will get no benefit from melatonin supplements because their body already produces sufficient amounts.

I think a lot of your problems can be improved with the help of others regarding your pressure settings.

Good luck,

[speppers]

Thank you so much for your feedback. Haha, I'm turning 26 this month, so perhaps you are right about my not needing the supplements. I wonder why a couple of physicians recommended it to me! Nevertheless, I'm going to read more into the smaller doses of melatonin. Thus far, it's not doing much to improve my sleep quality.

[ChicagoGranny]

Doctors should not recommend melatonin supplements to young people, except, as Seth mentions, for shift work changes or jet lag.

my sleep hygiene was perfect, including consistent bedtime and wake-up time.

What about diet and exercise?

[speppers]

What about diet and exercise?

I exercise (both cardio and strength training) from about 4-7 days per week and eat a healthy diet. Nevertheless, my diet is occasionally deficient in certain things (such as iron) and abundant in others (such as gelato). However, I do supplement with iron pills and was recently found to not be anemic (at present). I know that can cause fatigue and low blood pressure (which I also suffer from), and I typically have to keep up with the iron pills even when I'm not anemic.