I had asked advice on my Dad’s sleep back in March but some of the medical info I posted about my dad was based on an erroneous diagnosis, so I thought it best to just start a new thread.
viewtopic.php?f=1&t=183978&p=1407686#p1407686
I did not act on any of the great advice given back in March, I didn’t dare change anything because it turned out that my dad had critical heart issues. When we sought a second cardiologist’s opinion we learned the first cardiologist’s diagnosis of mild/moderate aortic valve stenosis was wrong, my dad actually had critical aortic valve stenosis.
Which brings me to today. My dad barely made it thru the surgery but 4 months ago he finally got a new aortic valve and a pacemaker. He’s doing better than before surgery, but is not doing as well as he had hoped.
Other issues he has are: multiple severe back problems, horrible arthritis in both shoulders + a torn rotator cuff, prostate/ bladder issues, and sometimes severe depression. For pain he tries to only take extra strength Tylenol, but when it gets unbearable he sometimes takes diclofenac or Aleve.
My dad feels recently his sleep has been getting worse. The majority of events both before and after surgery the machine shows as centrals. The month before surgery his average AHI was 6.27.
Following surgery monthly AHI averages have been: 4.78, 6.17, 6.08, 9.34.
I recently raised his minimum from 4 to 6, which he likes and finds more comfortable. It’s to soon to know, but I so far it doesn’t seem to be changing his overall average AHI.
I’m considering very slowly and gradually changing the EPR as Pugsy suggested might be worth a try back in March, but appreciate any new advice considering the changes in my dad’s health and overall sleep. Here are two recent screenshots first with minimum at 4 second at 6. On one I zoomed in on Cheyne Stokes which shows up in about 90% of nights, but my untrained eye thinks probably isn’t anything?
https://imgur.com/a/jhoc7yI
Any advice on how I could help my dad find a more restful nights sleep?
Thank you!
Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
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Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Is he sleeping halfway decent the first half of the night and then doing a lot of tossing and turning and having wake ups the second half of the night?
Or sleeping soundly for most of the night with minimal wake ups?
Or sleeping soundly for most of the night with minimal wake ups?
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Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
That is a great question! I also wondered why the first part of nearly all nights seem to look better than the last half. My dad is only remembers whether the night seemed good or bad, he isn’t aware of the details. My stepmom has told mentioned before that sometimes he tosses, turns, kicks, gasps, etc; but don’t know how frequent that is or if it it happens towards the end of the night. I’ll ask her about it and see if I can learn more.
Thanks as always for your help Pugsy, you’re amazing!
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Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
colomom,
I've read the original thread as well as what you've posted here.
I have more questions than answers for you, unfortunately.
Question 1: In the original thread at viewtopic.php?f=1&t=183978&p=1407686#p1407686 you say your father was diagnosed with severe OSA. How severe? And did you ever see the sleep study with summary data and the summary graphs?
Next you now write:
You also write:
Question 3 When your father says he finds the slight increase in minimum pressure more comfortable, does he mean he now feels like there is enough air coming in through the mask when he is awake?
It's important to note that while increasing the pressure seems to be increasing his comfort, higher pressure is not going to make the CAs go away: His airway is not blocked, so there's no need for more pressure to keep his airway from collapsing.
Now let's review everything you've said about your father's numerous medical conditions:
Once you know whether Cheyne Stokes is associated with the kinds of heart conditions your father has, you'll be better able to start analyzing his data for whether you are really seeing Cheyne Stokes or not.
Next, I think you ought to ask your dad how often he thinks he's waking up at night because of the pain from the back problems, the arthritis in the shoulders, and the torn rotator cuff. Also how often is he waking up from the prostate and bladder issues. Because if he remembers multiple wakes caused by the pain he is in, then it could well be that the CAs are part of sleep-wake-junk: He's restless and drifting in & out of sleep because of the pain and the CAs are simply his body not transitioning from the wake breathing to sleep breathing completely smoothly.
I think you and your father also may need to talk with his doctors about managing the pain. He may need to be more willing to take the diclofenac or Aleve sooner than he currently takes them. But at the same time, I can see why he doesn't want to take them all the time. Still---if he's in pain at bedtime, it may be that taking the Aleve or diclofenac may give him a more restful night, and hence better sleep.
It's also important to keep in mind that severe depression can play havoc with getting a good night's sleep even in people who don't have OSA, let alone the other conditions your father has. It may be worth asking whether treating the depression could help improve his sleep.
Finally you write:
I've read the original thread as well as what you've posted here.
I have more questions than answers for you, unfortunately.
Question 1: In the original thread at viewtopic.php?f=1&t=183978&p=1407686#p1407686 you say your father was diagnosed with severe OSA. How severe? And did you ever see the sleep study with summary data and the summary graphs?
Next you now write:
Question 2: Are those AHI numbers are what his machine was reporting? And for all of these AHI numbers, the centrals make up most of the events? What is his AHI - CAI? That helps us.colomom wrote: ↑Tue Sep 27, 2022 5:17 pmMy dad feels recently his sleep has been getting worse. The majority of events both before and after surgery the machine shows as centrals. The month before surgery his average AHI was 6.27.
Following surgery monthly AHI averages have been: 4.78, 6.17, 6.08, 9.34.
You also write:
Comfort is an important part of the PAP puzzle.I recently raised his minimum from 4 to 6, which he likes and finds more comfortable. It’s to soon to know, but I so far it doesn’t seem to be changing his overall average AHI.
Question 3 When your father says he finds the slight increase in minimum pressure more comfortable, does he mean he now feels like there is enough air coming in through the mask when he is awake?
It's important to note that while increasing the pressure seems to be increasing his comfort, higher pressure is not going to make the CAs go away: His airway is not blocked, so there's no need for more pressure to keep his airway from collapsing.
Now let's review everything you've said about your father's numerous medical conditions:
The first thing that I think you ought to do is talk to the cardiologist and ask whether Cheyne Stokes respiration is likely to be a problem with the specific kind of heart issues your father is known to have. Cheyne Stokes respiration patterns can occur when the patient is awake as well as when they are asleep. It's also worth noting that the characteristic waxing/waning breath pattern with CAs at the nadir of each cycle will typically continue for 45-75 minutes in Cheyne Stokes respiration. (See https://www.ncbi.nlm.nih.gov/books/NBK448165/.)When we sought a second cardiologist’s opinion we learned the first cardiologist’s diagnosis of mild/moderate aortic valve stenosis was wrong, my dad actually had critical aortic valve stenosis.
Which brings me to today. My dad barely made it thru the surgery but 4 months ago he finally got a new aortic valve and a pacemaker. He’s doing better than before surgery, but is not doing as well as he had hoped.
Other issues he has are: multiple severe back problems, horrible arthritis in both shoulders + a torn rotator cuff, prostate/ bladder issues, and sometimes severe depression. For pain he tries to only take extra strength Tylenol, but when it gets unbearable he sometimes takes diclofenac or Aleve.
Once you know whether Cheyne Stokes is associated with the kinds of heart conditions your father has, you'll be better able to start analyzing his data for whether you are really seeing Cheyne Stokes or not.
Next, I think you ought to ask your dad how often he thinks he's waking up at night because of the pain from the back problems, the arthritis in the shoulders, and the torn rotator cuff. Also how often is he waking up from the prostate and bladder issues. Because if he remembers multiple wakes caused by the pain he is in, then it could well be that the CAs are part of sleep-wake-junk: He's restless and drifting in & out of sleep because of the pain and the CAs are simply his body not transitioning from the wake breathing to sleep breathing completely smoothly.
I think you and your father also may need to talk with his doctors about managing the pain. He may need to be more willing to take the diclofenac or Aleve sooner than he currently takes them. But at the same time, I can see why he doesn't want to take them all the time. Still---if he's in pain at bedtime, it may be that taking the Aleve or diclofenac may give him a more restful night, and hence better sleep.
It's also important to keep in mind that severe depression can play havoc with getting a good night's sleep even in people who don't have OSA, let alone the other conditions your father has. It may be worth asking whether treating the depression could help improve his sleep.
Finally you write:
Turning EPR on is worth an experiment. Your dad may find that it increases his comfort. But if he doesn't feel more comfortable, then go back to turning it off.I’m considering very slowly and gradually changing the EPR as Pugsy suggested might be worth a try back in March, but appreciate any new advice considering the changes in my dad’s health and overall sleep.
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Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.
Correct number of posts is 7250 as robysue + what I have as robysue1
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Correct number of posts is 7250 as robysue + what I have as robysue1
Profile pic: Frozen Niagara Falls
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
robysue1 wrote: ↑Tue Sep 27, 2022 7:41 pm
Question 1: did you ever see the sleep study with summary data and the summary?
Question 2:Are those AHI numbers are what his machine was reporting? And for all of these AHI numbers, the centrals make up most of the events? What is his AHI - CAI? That helps us.
Question 3 When your father says he finds the slight increase in minimum pressure more comfortable, does he mean he now feels like there is enough air coming in through the mask when he is awake?
It's important to note that while increasing the pressure seems to be increasing his comfort, higher pressure is not going to make the CAs go away: His airway is not blocked, so there's no need for more pressure to keep his airway from collapsing.
The first thing that I think you ought to do is talk to the cardiologist and ask whether Cheyne Stokes respiration is likely to be a problem with the specific kind of heart issues your father is known to have. Cheyne Stokes respiration patterns can occur when the patient is awake as well as when they are asleep. It's also worth noting that the characteristic waxing/waning breath pattern with CAs at the nadir of each cycle will typically continue for 45-75 minutes in Cheyne Stokes respiration. (See https://www.ncbi.nlm.nih.gov/books/NBK448165/.)
Once you know whether Cheyne Stokes is associated with the kinds of heart conditions your father has, you'll be better able to start analyzing his data for whether you are really seeing Cheyne Stokes or not.
Next, I think you ought to ask your dad how often he thinks he's waking up at night because of the pain from the back problems, the arthritis in the shoulders, and the torn rotator cuff. Also how often is he waking up from the prostate and bladder issues. Because if he remembers multiple wakes caused by the pain he is in, then it could well be that the CAs are part of sleep-wake-junk: He's restless and drifting in & out of sleep because of the pain and the CAs are simply his body not transitioning from the wake breathing to sleep breathing completely smoothly.
I think you and your father also may need to talk with his doctors about managing the pain. He may need to be more willing to take the diclofenac or Aleve sooner than he currently takes them. But at the same time, I can see why he doesn't want to take them all the time. Still---if he's in pain at bedtime, it may be that taking the Aleve or diclofenac may give him a more restful night, and hence better sleep.
It's also important to keep in mind that severe depression can play havoc with getting a good night's sleep even in people who don't have OSA, let alone the other conditions your father has. It may be worth asking whether treating the depression could help improve his sleep.
Turning EPR on is worth an experiment. Your dad may find that it increases his comfort. But if he doesn't feel more comfortable, then go back to turning it off
Thank you Robysue1, lots of great questions and insights!
Question 1 (sleep study results):
AHI/CAI:
My dad had a home sleep study ordered by PCP. Findings were: Severe Obstructive OSA
AHI 37.9; AI 32.9; total obstructive apnea events 231, unclassified apneas 13, hypopneas 18 lowest O2 76%, O2 below 90% 14%
Snoring over 50dBa 96%
Question 2 (breakdown of machine reported AHI:
AHI/CAI
Before surgery 6.27/4.09 Following surgery 4.78/3.09, 6.17/4.45, 6.08/4.43, 9.34/7.55
Question 3 (comfort with increased pressure):
My father finds the extra pressure more comfortable while awake. In addition to all the other stuff I listed he also has a deviated septum and horrible allergies. While awake he finds it much easier to breathe thru his nasal mask at 6 rather than 4.
The rest of your advice is golden, but sadly not easily obtainable in my dad’s case. I wish the doctors would do something more for dad’s pain. He is tries to only take Tylenol and avoid taking NSAIS because the docs told him the NSAIDS will further damage his heart. His depression has been a lifelong struggle, I’ve spent my lifetime trying to help him navigate it and encouraging him to medically treat it but i’ve been unsuccessful.
Both my dad and I live in small towns and he lives 3 hours from me. My dad can no longer drive and while his wife can drive around still drive around their small town she can’t drive him to see the cardiologist in the city. I’m happy to drive my dad to his specialist appointments but every specialist appointment I drive him to is 11 hours of driving for me, so even when I make appointments for him my dad more often than not cancels his cardiologist appointments because he feels guilty about inconveniencing me. He’s also 81 years old, stubborn, and has has some really bad experiences with doctors.
I continue to try to do my best to convince my dad to see the docs he should see, but in the meantime I think the best I can do for him is try to figure out on my own if there is anything that can be done to help his hopefully make his sleep at least a bit better.
Thanks again for all your help!
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Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
The "CSR" is definitely not as it doesn't come close to meeting criteria.
I would think he has had a recent ejection fraction done following all this. If that's normal that should add to putting your mind at ease.
That's probably just a lot of SWJ. You might want to consider a Sleep Tracker as IMO you need to try to get him some more quality sleep. They're accurate enough to establish trends.
Have you seen a physician specifically credentialed in pain management?
I would think he has had a recent ejection fraction done following all this. If that's normal that should add to putting your mind at ease.
That's probably just a lot of SWJ. You might want to consider a Sleep Tracker as IMO you need to try to get him some more quality sleep. They're accurate enough to establish trends.
Have you seen a physician specifically credentialed in pain management?
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Thanks Rubicon, you have a great point about putting concerns about my dad’s heart in perspective. My dad has had 2 post surgery echos and his new valve is looking good!Rubicon wrote: ↑Wed Sep 28, 2022 5:05 amThe "CSR" is definitely not as it doesn't come close to meeting criteria.
I would think he has had a recent ejection fraction done following all this. If that's normal that should add to putting your mind at ease.
That's probably just a lot of SWJ. You might want to consider a Sleep Tracker as IMO you need to try to get him some more quality sleep. They're accurate enough to establish trends.
Have you seen a physician specifically credentialed in pain management?
I’ve thought about a sleep tracker, but worry that something like that could increase his anxiety about his sleep and overall health. My dad was an engineer and is very detail orientated and meticulous, if he had something detailing every night of sleep he would analyze all the data each morning and likely would have anxiety over problems that show up that may not be fixable.
He has seen a pain doc, unfortunately the doc didn’t have much to offer.
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Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Less perspective and more understanding. CSR is causing by circulatory delay. If his EF is normal then that would be more support that the centrals are from SWJ.
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Or, OR..colomom wrote: ↑Wed Sep 28, 2022 4:44 pmI’ve thought about a sleep tracker, but worry that something like that could increase his anxiety about his sleep and overall health. My dad was an engineer and is very detail orientated and meticulous, if he had something detailing every night of sleep he would analyze all the data each morning and likely would have anxiety over problems that show up that may not be fixable.
Problems would show up up that would be fixable.
Specifically if your concerns are
My dad feels recently his sleep has been getting worse. The majority of events both before and after surgery the machine shows as centrals. The month before surgery his average AHI was 6.27.
Following surgery monthly AHI averages have been: 4.78, 6.17, 6.08, 9.34.
a sleep tracker could help determine if his sleep efficiency is 50% or 90%, if his sleep AHI is 6.00 or 0.00, what exactly needed to be addressed, and yes, analyzing the data each morning to see what improvements can be made. Few problems are "unfixable", and anyway IMO knowing whether a problem is fixable or not gives me less anxiety, not more.
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
After you get the sleep tracker and figure out if sleep efficiency is normal or not, find another pain doc.
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
You've inspired me to go back to one of my previous sigs...colomom wrote: ↑Tue Sep 27, 2022 5:17 pmI recently raised his minimum from 4 to 6, which he likes and finds more comfortable. It’s to soon to know, but I so far it doesn’t seem to be changing his overall average AHI.
I’m considering very slowly and gradually changing the EPR as Pugsy suggested might be worth a try back in March, but appreciate any new advice considering the changes in my dad’s health and overall sleep.
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Another favorite sig is
A problem is a problem only if it's a problem.
As noted by a previous poster
Does he need a more restful night's sleep? How's his function during the day?
I mean, if he's a short-sleeping ASPS (and I am an expert on that) targeting 7.5 hours sleep per night might be asking too much. Add the pain in and at 0200 he's ready to start the day.
When does he take pain meds? If he needs analgesia at 0200 maybe you need some strategy there (or get sustained-release/longer-acting something). Or if it's really sleep maintenance insomnia a short-acting sleep aid to take in the middle of the night.
Polyphasic sleeping? No law that says you can't!
A problem is a problem only if it's a problem.
As noted by a previous poster
IMO he might not be sleeping here at all:
The first question to ask is:
Does he need a more restful night's sleep? How's his function during the day?
I mean, if he's a short-sleeping ASPS (and I am an expert on that) targeting 7.5 hours sleep per night might be asking too much. Add the pain in and at 0200 he's ready to start the day.
When does he take pain meds? If he needs analgesia at 0200 maybe you need some strategy there (or get sustained-release/longer-acting something). Or if it's really sleep maintenance insomnia a short-acting sleep aid to take in the middle of the night.
Polyphasic sleeping? No law that says you can't!
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
Maybe it's time to move them closer to you (yep, not an easy decision. Been there, done that, got the T-shirt. Welcome to old!)colomom wrote: ↑Tue Sep 27, 2022 10:09 pm
Both my dad and I live in small towns and he lives 3 hours from me. My dad can no longer drive and while his wife can drive around still drive around their small town she can’t drive him to see the cardiologist in the city. I’m happy to drive my dad to his specialist appointments but every specialist appointment I drive him to is 11 hours of driving for me, so even when I make appointments for him my dad more often than not cancels his cardiologist appointments because he feels guilty about inconveniencing me. He’s also 81 years old, stubborn, and has has some really bad experiences with doctors.
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.
Make each sensation a little bit stronger.
Experience slips away.
Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
That's what I was thinking as well. That mess looks more SWJ ish than anything to me plus its a known fact that there are some sleep issues and potentially some pain issues going on.
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Re: Advice on Dad’s centrals, Cheyne Stokes, and overall worsening sleep
I have very little understanding about CSR. His EF has always been fine (even before heart surgery). I should have given a more detailed description about his heart. The new aortic valve is looking good, but there are still other issues. He has numerous areas of calcification, moderate mitral valve stenosis, a dual chamber pacemaker, coronary artery disease, and pulmonary hypertension.Rubicon wrote: ↑Thu Sep 29, 2022 2:10 amLess perspective and more understanding. CSR is causing by circulatory delay. If his EF is normal then that would be more support that the centrals are from SWJ.
After you get the sleep tracker and figure out if sleep efficiency is normal or not, find another pain doc.
a sleep tracker could help determine if his sleep efficiency is 50% or 90%, if his sleep AHI is 6.00 or 0.00, what exactly needed to be addressed, and yes, analyzing the data each morning to see what improvements can be made. Few problems are "unfixable", and anyway IMO knowing whether a problem is fixable or not gives me less anxiety, not more.
After you get the sleep tracker and figure out if sleep efficiency is normal or not, find another pain doc.
The first question to ask is:
Does he need a more restful night's sleep? How's his function during the day?
I mean, if he's a short-sleeping ASPS (and I am an expert on that) targeting 7.5 hours sleep per night might be asking too much. Add the pain in and at 0200 he's ready to start the day.
When does he take pain meds? If he needs analgesia at 0200 maybe you need some strategy there (or get sustained-release/longer-acting something). Or if it's really sleep maintenance insomnia a short-acting sleep aid to take in the middle of the night.
Polyphasic sleeping? No law that says you can't!
Maybe it's time to move them closer to you (yep, not an easy decision. Been there, done that, got the T-shirt. Welcome to old!)
You and Pugsy are likely correct in your suspicions that many of his centrals are likly SWJ. There are 3 primary issues that likely impact his sleep but for everything with exception of mental health we have been told there isn’t much that can be done to fix the problems. The number one problem is pain. His shoulders are both bone on bone, he can’t even lift his arms high enough to button his shirt. He’s had lots of steroid injections, but they never seem to help. His back is a mess; he has severe scoliosis, arthritis, and stenosis. He had back surgery about 10 years ago in which they removed a spinal tumor that caused cauda equina syndrome and they also did some laminectomies while in there. Unfortunately, while they were able to remove nearly all of the spinal tumor there had been some permanent nerve damage which caused loss of bladder function (he now uses a foley cath). Like most men his age he also has an enlarged prostate. His urologist had been considering some minor surgeries to help with the prostate, but with all the heart stuff she no longer advises any kind of surgery. Before CPAP he was getting up 3-4 times a night to urinate, with CPAP there’s been a huge improvement and he now only gets up once. No doubt mental health issues also impact his sleep. His mental health has gotten bad enough to warrant hospitalization a number of times over the years. When he gets in a really low place it certainly can impact his sleep. Sometimes while sleeping he’ll become agitated and will hit himself. When he wakes up from these episodes because he is in a highly agitated state it is difficult to go back to sleep. I agree with you that a sleep tracker could be helpful, but at this moment in time my dad seems to be headed into a mental downward spiral. Anxiety over his health and obsessive thinking patterns can feed his depression. I would love to try a sleep tracker out once he gets back to a better place mentally. Any suggestions on a good one?
I would love for him to see another pain doc, but he isn’t willing. With the cath and the pain, the last thing my dad wants to do is travel even further to see better specialists. I’m also not confident that there is much more that can be done for the pain. The cardiologist doesn’t want him on NSAIDS and he’s been down the opioid path before which isn’t a good path to be on. He does time his pain meds for sleep, he takes his extra strength Tylenol 30 minutes before bed and keeps some by his bedside which he takes if he wakes up with bad pain and enough time has passed from the last dose.
A sleep aid during the night is a good idea, any advice on a good sleep aid to try?
Getting him to move closer is also a good suggestion, we’ve talked about it many times and it might happen one day. I live in Colorado and he lives in Utah, but he owns a house in the Colorado town I live in so it wouldn’t be hard for him to relocate here. The main drawbacks with him moving back to Colorado are the snow and higher elevation (I’m at 7,000 feet).
Thanks again for the great suggestions!
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