Noctuary wrote:robysue wrote:3) How long have you been taking the Temazepam?
I have five months refills I can get. I guess it was as needed.
Which came first: The temazepam prescription or the start of CPAP therapy?
Regardless of which came first, I'd talk to the doc who prescribed the temazepam if I were you. While hypnotics are typically intended for short term use for transient, severe insomnia, there are times when they are an important tool for dealing with chronic, severe insomnia problems. However, it's important that both the doc and the patient understand what the goals of the drug therapy are and what the exact instructions on taking the drug are.
For example, two summers ago my CPAP-induced insomnia returned big-time and the usual attention to sleep hygiene just wasn't cutting it in terms of keeping the insomnia monster under control. After doing additional testing that documented the problem, but did nothing to identify the underlying cause, my sleep doctor explained to me
why he wanted me taking Ambien every night for a month or two. I had been very reluctant to do that, but I agreed to trying it his way. While taking the Ambien nightly for a couple of months didn't "solve" all my problems, it did help bring the insomnia back under control enough where I was no longer feeling like I wasn't getting any restorative sleep on half or more of the nights. And at that point I was able to back off to taking the Ambine on an "as needed" basis.
Noctuary wrote:robysue wrote:6) You've mentioned depression in some of your previous posts.
...
If you have not had a chat with your doc about your depression, you should mention this problem as well as your on going issues with the lack of high quality sleep.
I've been depressed my whole life.
...
My current doctor knows about my depression;
I won't tell him the extent of it nowadays. He knows of my fatigue and prescribed me Provigil, which is worthless. I am going to call my alternative doctor tomorrow and set up an appointment.
You need to tell the doctor(s) the extent of your depression nowadays.
Seriously: Regardless of how you wish to treat your depression symptoms, you need to be open with your doctor(s) about the extent of those symptoms. Untreated or undertreated depression can lead to both daytime fatigue and nighttime sleep problems. If the depression has gotten worse since you've been put on CPAP, that's an important thing that the doc needs to be made aware of. Yes, I can understand that you may be very reluctant to tell the doctor about the worsening depression because you are worried about having unwanted medication being pushed as a solution. But you still need to have this conversation with the doc(s) even if you reject the idea of taking antidepressants.
Noctuary wrote:But this condition of sleep apnea, or whatever is causing my poor sleep, literally came on overnight. I had been sleeping well for years, then one day I woke up feeling terrible. This was incidentally a few days after I went to the hospital for pains in my shoulders and neck (it wasn't a heart attack after all). I often wonder if I caught something there.
There are at least five things that may need to be teased out of your medical history and your current sleep problem symptoms:
1)
The role of your OSA in terms of your sleep problems prior to your OSA diagnosis. Here's the thing:
OSA does not "come on overnight". Nor is OSA something you can "catch" from being in the hospital. OSA is a chronic condition that develops over time, and the symptoms usually develop slowly---so slowly that many people with OSA simply redefine what "normal for them" means through the years without ever really realizing just how bad their sleep is. And there is also a fair amount of variability in how severe the OSA symptoms are from person to person. Some people with OSA strongly suspect that apnea is a problem and know they're not sleeping well and have horrible daytime fatigue and sleepiness, and when the sleep study is done, their OSA turns out to be rather mild with an AHI around 10. Other people have no clue that they've got OSA, don't seem to have many symptoms and think they sleep very well each night, but because their bedpartner complains of snoring, they have a sleep test done and it shows very severe OSA (AHI >> 30) and significant O2 desats. So you have to understand that when you say you had been "sleeping well for years", that may be true---in the sense of how your sleep felt
subjectively in the sense of your having had no memory of night time wakes and having had enough energy to get through your days, but at the same time it may have been
objectively bad in terms of what was actually happening to your body each and every night.
2)
Is there is some specific cause (other than untreated OSA) for the sudden seemingly overnight deterioration in the quality of your sleep? Pain can trigger sleep problems. Perhaps the severe pain that lead you to going to the hospital (in fear that it was a heart attach?) may have been the trigger for the sudden deterioration in the subjective quality of your sleep. But if that was the trigger, then the question becomes:
Why didn't the sleep return to normal after you got the good news that the pain was NOT a heart attack? Perhaps your sleep didn't recover because the
bad sleep that was triggered by the pain allowed your body and mind to start noticing the damage being done by the OSA each night. Perhaps the hospitalization for the pain triggered some severe anxiety, which has lead to on-going sleep problems. Perhaps the hospitalization has lead to a worsening of the depression, and the depression symptoms are now manifesting themselves in terms of
bad sleep for the first time.
3)
The timing between the sudden decrease in sleep quality, your diagnostic sleep test and its results, and the initiation of CPAP therapy; and how each of these things has affected your on-going problems with depression. While its clear to you what the order of events is, it's not yet clear to me. (I admit: I've not taken the time to re-read all your posts, and the answer is most likely there.) It seems to me from what I've been reading that the order of events is:
- The hospitalization with the pain that turned out to NOT be a heart attack.
- A sudden decrease in sleep quality.
- The diagnostic sleep test, with results that showed you have OSA. (Why were you referred for a sleep test? How bad is the untreated OSA?)
- Starting CPAP, with the results being a further deterioration in the quality of your sleep.
- A relatively recent increase in middle-of-the-night wakes with the inability to get back to sleep, along with wake-too-early wakes.
And along with the on-going deterioration of the sleep quality, you've been dealing with an increase in the depression symptoms and in the daytime fatigue.
4)
The role of APAP in agravating your current sleep problems. There is some evidence that pressure increases may be triggering wakes or at least increasing the restlessness you have during the night time. And unfortunately, when you wake up in the middle of the night, you have a tough time getting back to sleep. Capping the max CPAP pressure at the lowest level that keeps the OSA under control may help prevent pressure spikes from triggering wakes. But there's more to high quality sleep than just "not waking up." Still, preventing the wakes is
an important part of the solution to your overall sleep problems.
5)
The role your long-term depression problems might have in terms of your current bad sleep problems. Yes, I know: You've been depressed for years, but you've also been sleeping well for years. But the thing is, as you get older and/or as the depression gets worse, the way the depression manifests itself in your daily life can change. It's possible that after the hospitalization and the pain-induced short-term sleeping problems, that the depression started to manifest itself in terms of bad sleep quality. And that after starting CPAP to address the OSA problems, the depression-related
bad sleep problems didn't resolve because they're rooted in the depression, not the OSA. So treating the OSA is good for the body (in terms of preventing furhter OSA-related damage), but has not resulted in fixing your overall sleep problems because the problems you are most noticing are caused by the depression and not the OSA or CPAP.
Finally, there's this:
It may be time to stop worrying about the cause of the current sleep difficulties, and start working on fixing the sleep problems. That will require a shift in mind set (which is hard to do) and a shift in expectations (which is also hard to do). In particular:
A)
Set reasonable, achievable interum goals in regards to your sleep quality. You need to face the fact that nothing is going to be a "magic bullet" and fix all your sleep problems in a very short time frame. Rather, you need to have some achievable goals that mark steps in the right direction. And you need to allow yourself to
celebrate small victories, even if you are still feeling pretty lousy most of the time. If you have a night where you only wake up once or twice, but you're able to get back to sleep, that's
progress even if you don't feel much better during the following daytime. So allow yourself the luxury of celebrating that progress instead of fixiating on the fact that you still feel pretty bad during the daytime.
B)
Continue working on finding a pressure that controls the OSA but also does not seem to trigger or increase the night time wakes and overall restlessness. By itself this probably won't make much difference in terms of how you feel, but if you don't do this, you won't ever get to where you want to be. In math speak: Finding a good pressure range is a
necessary condition for fixing your problems, but it is not a
sufficient condition for fixing your problems.
C)
Start working on addressing sleep hygiene issues.
- You need to establish a regular wake up time, regardless of how little or how much sleep you get the night before. Yes, it makes for some really bad days, but this is critical in training your body to understand that Time in bed = time to sleep.
- Work on figuring out an appropriate bedtime for yourself. If you never get more than 6 hours of sleep, there's very little reason to go to bed 8 hours before your designated wake up time. Spending a lot of time in bed not sleeping is exhausting and can make you feel wiped out the next morning. If you only get 6 hours of sleep on your best nights, then bedtime should be about 6.5-7 hours before wake up time.
- Clarify how the doctor intends for you to take the Temazepam, and take it as directed. If the Temazepam stops working or seems to be ineffective, let the doctor know what's happening.
- Work on other sleepy hygiene issues: Try to limit or eliminate caffeine after noon. Pay attention to when you eat supper and what kinds of things you choose to eat for late night snacks. Try to limit/eliminate using electronic gadgets during the last hour or two before going to bed. Don't use the bedroom for anything other than sleeping and sex.
D)
Work on addressing the depression issues. If the depression has increased substantially since starting CPAP, then some of your ongoing symptoms are likely caused by the increased depression. How to address the depression issues is something you must decide, prefereably in consultation with a doctor whom you trust.
