(extracted from CHEST Magazine, 12/2014)

Patients with obstructive sleep apnea (OSA) may improve their memory by using Continuous Positive Airway Pressure(CPAP). A study published in the December issue of CHEST shows that the majority of patients with OSA, who were memory-impaired prior to treatment, demonstrated normal memory performance after 3 months of optimal CPAP use. The study also showed that memory improvement varied based on CPAP adherence. Patients who used CPAP for at least 6 hours a night were nearly eight times as likely to demonstrate normal memory abilities compared with patients who used CPAP for 2 or fewer hours a night.

“Patients with OSA often complain of daily forgetfulness, e.g., losing their keys, forgetting phone numbers, or forgetting to complete daily tasks,” said author Mark S. Aloia, PhD, National Jewish Medical and Research Center in Denver, “Where memory is concerned, we may have the ability to reverse some of the impairments by providing effective and consistent use of CPAP treatment.”

Dr. Aloia and colleagues examined the degree to which varying levels of CPAP adherence improved memory in 58 memory-impaired patients with clinically diagnosed OSA. All patients underwent cognitive evaluation involving verbal memory testing prior to initiation of CPAP and at a 3-month followup visit. Patients were prescribed CPAP machines, and adherence was monitored using internal microprocessors within each device. After treatment, patients were divided into three groups based on their 3-month CPAP adherence: (1) 14 poor users, patients who averaged fewer than 2 hours/night of CPAP use; (2) 25 moderate users, patients who averaged 2 to 6 hours/night of CPAP use; and (3) 19 optimal users, patients who averaged more than 6 hours/night of CPAP use.

At baseline, all patients were found equally impaired in verbal memory. Following 3 months of CPAP treatment, 21 percent of poor users, 44 percent of moderate users, and 68 percent of optimal users demonstrated normal memory performance. Compared with poor users, optimal users of CPAP were nearly eight times as likely to demonstrate normal memory abilities.

“Moderate use of CPAP may help, but it might not allow patients to reach their full potential recovery where memory is concerned, especially if memory is impaired at baseline. For patients with OSA, the more regularly and consistently they use CPAP, the better off they will be,” Dr. Aloia said.

SLEEP APNEA TERMS

(Courtesy of Wake Up To Sleep)

What do certain sleep apnea treatment terms mean?

What is AHI?

apnea–hypopnea index is the number of apneas and hypopneas experienced by a person per hour of sleep. An AHI of:
0–4 is normal
5–14 denotes mild sleep apnea
15–29 denotes moderate sleep apnea
30+ denotes severe sleep apnea

Types sleep apnea

Obstructive sleep apnea (OSA): Stopped airflow for at least 10 seconds due to a “mechanical” obstruction such as a tongue relaxed to the back of the throat, a semicollapsed pharynx or a large amount of tissue in the uvula area (84% of sleep apnea patients)

Central sleep apnea (CSA): Stopped airflow for at least 10 seconds due to an irregularity in the brain’s control of one’s breathing (15% of sleep apnea patients) Complex sleep apnea (CompSA): when a person’s OSA becomes CSA after they begin CPAP treatment (1% of sleep apnea patients)

Sleep Tests

Polysomnography (PSG): An overnight sleep study, with sensors placed on the body to record physiologic signals and diagnose many types of sleep disorders CPAP titration study: When a sleep technician uses a CPAP machine to find the minimum air pressure needed to help a person eliminate all apneas, hypopneas and snoring

Split-night study: A single overnight test that includes a PSG and a CPAP titration (learn more)

Home sleep test: A device to diagnose sleep apnea at home

CPAP Machines

CPAP (continuous positive airway pressure): Delivers air at a single, constant pressure that keeps your airway open

Bilevel: Delivers a higher air pressure when you inhale and a lower one when you exhale, so you can breathe out easier APAP (automated positive airway pressure): Detects and provides the minimum amount of air pressure a person needs to avoid an apneic event. This pressure changes throughout the night, based on his/her needs

ASV (adaptive servo-ventilation): Learns your normal breathing volume while you’re awake and provides the needed pressure support to maintain that pattern while you sleep. ASV has shown to be effective for CSA (central sleep apnea) patients,

Other terms

Apnea: When a person stops breathing in his/her sleep for at least 10 seconds

EEG(electroencephalogram): Measures brain activity; used during an in-lab sleep study

EKG (electrocardiograph): Measures heart activity; used during an in-lab sleep study or home sleep test

EMG (electromyogram): Measures muscle activity; used during an in-lab sleep study

EOG (electrooculogram): Measures eye movement; used during an in-lab sleep study Full face mask: A CPAP mask that covers the nose and mouth

Hypersomnia: excessive daytime sleepiness, a common symptom of sleep apnea

Hypopnea: When a person’s upper airway is reduced by 30% or more for at least 10 seconds, coupled with a 4% drop in blood oxygen.

Nasal mask: A CPAP mask that covers the nose

Nasal pillows: The smallest, lightest type of CPAP mask, which rests at the base of the nose

Oximeter: Measures the level of oxygen in a person’s blood stream, placed on the fingertip or ear

REM (rapid eye movement): A cycle of sleep staging characterized by rapid, shallow or irregular breathing, rapid eye movements and temporary muscle paralyzing when the brain waves are very active

Sleep architecture: Your entire sleep (how long it takes you to fall asleep, how long you’re in each sleep stage, when you wake up during the night and for how long, etc.), determined by analyzing a person’s EEG and EOG

Sleep stages: Wakefulness, non-REM stages 1, 2, 3 (with increasing depth), and REM (the deepest stage)

Snoring: The sound produced when air forces itself through a narrowed airway, vibrating the soft palate at the back of the throat. While not everyone who snores has sleep apnea, it is still “the most sensitive and strongest predictor of sleep apnea.”

WHY USE A CPAP
HUMIDIFIER?

(courtesy of ResMed)

What exactly does a CPAP humidifier do and how can you get the most out of it? It’s always helpful to revisit basic sleep apnea treatment questions like these to make sure we have the best information about our own treatment, and to make note of tips and tricks we haven’t tried yet.

A CPAP humidifier helps you avoid dry mouth (which nearly 40% of CPAP patients experience) along with dry nose, running nose, chapped lips, sinus-type headaches and nose bleeds – all by doing a simple job that our noses usually perform on their own. When we breathe naturally, our noses act as humidifiers, warming up the inhaled air to our bodies’ own temperature so that it’s more comfortable to breathe, won’t damage the delicate tissues of our upper airway and lungs, and won’t wake us up, as cold air might. Air coming through a CPAP machine needs its own humidification because it’s entering our upper airway faster than our noses can warm it. This is especially true for those who live in colder or drier climates and/or require high pressures.

The first CPAP machine was invented in 1980. In the late 80s, sleep specialists began humidifying CPAP air by sending it through a chamber of room-temperature water wherein it would pick up what little moisture evaporated as it entered the patient’s tubing. This method was called passive or passover humidification, and was not very effective.

The logical next step was to heat the water itself to create more vapor for the air to absorb. And so heated humidification began in the mid-1990s.

In 2001, Chest published a study that showed humidification “significantly improves patients’ CPAP compliance, and that its need may be predicted” if patients are over 60, taking oral medications that list dry mouth as a side effect, or had prior surgery to remove tissue from their throat. Of course, we now know that humidification can make sleep apnea treatment more comfortable, especially for patients on higher pressures, which is why more CPAPs come with an attached humidifier today. You can remove it if you want and insert a cap on that end of your machine. Two side effects and how to avoid them Humidification has two main side effects: One is that you may still experience dryness-related symptoms if your humidifier’s temperature is set too low.

The second, more common side effect is called rainout. It occurs when heated air cools in your tubing and reaches your mask as water, causing you to get a damp face. “Rainout” can be avoided by using a heated tube and adjusting the temperature of the tubing and/or the level of humidification that your water chamber is producing.

e-READERS MAY DISRUPT SLEEP

(extracted from HealthDay News, 1/02/15)

Light emitted by a tablet like an iPad can disrupt sleep if the device is used in the hours before bedtime, according to a new study published in the Proceedings of the National Academy of Sciences.

In the study, 12 adults read for about 4 hours before bedtime on 5 consecutive evenings, in a very dimly lit room at the hospital. Half read ebooks and the rest read printed books. After that, they spent another 5 evenings reading at the hospital, only they traded their books for printed books and vice versa/ Participants reading an e-book took longer to fall asleep than when they read a printed book. The e-readers also rated themselves as feeling less sleepy, and spent less time in rapid eye movement (REM) sleep.

Blood drawn from the participants revealed that using an e-book reader delayed the natural nightly increase in their melatonin levels by more than an hour and a half, compared with when they read a printed book.

The following day, participants who read an ebook said they woke up feeling sleepier and took longer to fully wake up and become alert, according to the researchers.

Measurements taken by the research team found that iPads emitted heavy doses of bluewavelength light, which has been shown in previous research to suppress melatonin and increase alertness. Other light-emitting e-readers also display large amounts of blue light, as do laptops, cell phones, light-emitting diode monitors and other electronic devices.

“Bright light tends to make your brain think the sun is up. When you click it [an e-reader] off to go to sleep, you will have trouble getting to sleep,” W. Christopher Winter, MD, medical director of the Jefferson Hospital Sleep Medicine Center and president of Charlottesville Neurology and Sleep Medicine, told HealthDay.

The researchers concluded: “Overall, we found that the use of portable light-emitting devices immediately before bedtime has biological effects that may perpetuate sleep deficiency and disrupt circadian rhythms, both of which can have adverse impacts on performance, health, and safety.”

DRUGS THAT NEGATIVELY AFFECT SLEEP

(Thomas L. Lenz, PharmD, MA, PAPHS, FACLM Am J Lifestyle Med. 2014;8(6):383-385).

Getting adequate sleep is a healthy lifestyle activity that is important for the body to function optimally both physically and mentally. Unfortunately, 70 million Americans suffer from chronic sleep loss or sleep disorders. Secondary causes of sleep disorders are often overlooked and can occur from the consumption of social or medicinal drugs. Common social drugs that can disrupt sleep include alcohol, caffeine, and nicotine. Certain medications can also have side effects that can induce sleep disruptions. This article briefly reviews common social drugs and prescription medications that can negatively impact sleep.

There are many reasons why 70 million Americans are not getting adequate sleep. At least 40 million are affected by a sleep disorder. The 4 most common sleep disorders are insomnia, sleep apnea, restless leg syndrome, and narcolepsy. Secondary causes of sleep disorders can be easily overlooked. Medications can be a secondary culprit for some sleep disorders and should be evaluated in patients suffering from sleep loss. The purpose of this article is to briefly discuss common drug related causes of sleep loss.

Alcohol and Sleep
Although alcohol is not classified as an medication, it is certainly classified as a social drug. In the United States, approximately 50% of adults drink alcohol on a regular basis and another 14% drink occasionally. Alcohol has been shown to have both a positive effect and a negative effect on health, depending on amount consumed and the timing of the consumption. Sleep has been shown to be negatively affected by alcohol consumption.

Consuming an alcoholic drink prior to bedtime, or “having a nightcap,” is a solution that some individuals use to solve sleep disorders. A cocktail or glass of wine may help some to relax and fall asleep more easily. However, alcohol has been shown to disrupt sleep a few hours later.

Alcohol can disrupt certain stages in the sleep cycle (specifically non–rapid eye movement [REM] Stage 3 and REM stage) that are necessary for “restorative” sleep. This often results in keeping these individuals in the “lighter” stages of sleep with more frequent awakenings during the night to urinate. Additionally, an overconsumption of alcohol prior to bedtime can result in excessive muscle relaxation, including those muscles in the pharynx. This can exacerbate snoring and increase the risk for sleep apnea. As a result, individuals who have a “nightcap” prior to bedtime generally do not wake in the morning fully rested.

Caffeine acts as a stimulant that can increase heart rate, blood pressure, mental alertness, and temporarily reduce fatigue. Caffeine can be found in many items that we consume on a daily basis. Some of the most common sources of caffeine include coffee, tea, and soda. Caffeine is also commonly found in chocolate, energy drinks, herbal products, and in overthe- counter and prescription medications. People vary widely on their sensitivity to the stimulant effects of caffeine, which can begin within 15 minutes and last up to 7 hours.

The amount of caffeine in the average 8 ounce cup of coffee is about 133 mg. The caffeine content in 8 ounces of tea and 12 ounces soda can range from 40 to 120 mg and 35 to 72 mg, respectively. Chocolate can contain about 9 to 33 mg of caffeine depending on serving size and energy drinks can contain up to 300 mg of caffeine in a 20 ounce serving. Additionally, herbal products can contain varying amounts of caffeine based on the product and quantity in which it is sold.

Caffeine is also included in many over-thecounter and prescription pain relievers, especially those targeted toward headache relief. Caffeine has been shown to speed the absorption of analgesics like aspirin and as a result provide quicker headache relief. The amount of caffeine included in pain relievers can range from 16 to 65 mg per dosage form (pill). The dosing regimen for many pain relievers suggests that patients take 2 pills per episode (e.g., headache). This can result in as much as 130 mg of caffeine and, in turn, induce sleep disorders in some patients.

Nicotine and Sleep
Nicotine is a stimulant similar to caffeine. The consumption of Nicotine, regardless of route, can result in increased heart rate, blood pressure, and respiratory rate. The stimulant effects from nicotine can last for several hours and can affect an individual’s ability to fall asleep and/or stay asleep. Additionally, withdrawal symptoms from nicotine can begin within a few hours of the last cigarette. Nicotine withdrawal symptoms can include restlessness, irritability, headache, lighter sleep, and frequent nighttime awakenings. Individuals who use nicotine often experience poor sleep quality and suffer from daily fatigue.

Prescription Medications
Similar to over-the-counter medications, certain prescription pain medications can contain caffeine. Two such products, Fioricet and Fiorinal, each contain 40 mg of caffeine per tablet. Depending on patient sensitivity, this amount of caffeine may adversely affect sleep in some individuals.

There are several other common prescription medications that induce sleep disorders that are unrelated to the stimulant effects of caffeine. The specific cause(s) for this in many medications is largely unknown and the degree to which patients experience these side effects varies widely. The following is a brief list of common drug classes and their potential sleep disruptive symptoms.

SSRIs (Selective Serotonin Reuptake Inhibitors)
Studies have shown that patients taking SSRIs can experience sleep disorder symptoms such as restless leg syndrome, insomnia, nonrestorative sleep, and daytime sleepiness. Examples of medications in this drug class are citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac).

Tricyclic Antidepressants
Medications in this class of drugs have shown to disrupt sleep by increasing the potential for restless leg syndrome and insomnia. They have also been shown to increase daytime sleepiness and morning grogginess, most likely due to their negative effects on restorative sleep patterns. Examples of tricyclic antidepressants include amitriptyline, amoxapine, and clomipramine.

Angiotensin-converting Enzyme (ACE) Inhibitors
A well-known class side-effect of ACE inhibitors is cough. For many patients, the “ACE cough” worsens at nighttime. This side effect can make it difficult to sleep and may also worsen sleep apnea. Examples of common ACE inhibitors include: benazepril (Lotensin), captopril (Capoten), and lisinopril (Prinivil).

Corticosteroids
Oral corticosteroids have been linked to sleep disorders such as sleep onset insomnia (difficulty falling asleep), sleep maintenance insomnia (difficulty staying asleep), and abnormal dreams. Examples include: methylprednisolone (Medrol), prednisolone, and prednisone.

Statins
The sleep disorders linked with statin medications include sleep onset insomnia, frequent awakening at night, and daytime fatigue. The muscle soreness that can occur with taking a statin medication has also been reported to disrupt sleep. Examples of statin medications include atorvastatin (Lipitor), rosuvastatin (Crestor), and simvastatin (Zocor).

Conclusion
Restorative sleep is an important lifestyle activity. Sleep loss affects many Americans and can lead to negative health consequences. Certain social and medicinal drugs have been shown to secondarily cause disruptive sleep in certain individuals. Health care providers should be advised to check for drugs that negatively affect sleep when talking with patients about sleep disorders.

WHY DOES MY AHI INDEX CHANGE?

(from “Wake Up to Sleep,” Jan 2015)

A CPAP patient told us that over the previous week her apnea–hypopnea index (AHI) had fluctuated between 1.9 and 5. She said she hadn’t had a “5” in 10 years, but now they were coming every other night even though her CPAP machine was reporting a good mask fit each morning. Concerned, she asked if it’s normal for AHI to go up and down from night to night.

The short answer is: Yes; it is normal for AHI to vary within reason. An AHI less than 5 is considered normal, and some patients with severe sleep apnea may be told by their doctor that they can accept even higher numbers so long as they’re feeling more rested each morning, experiencing fewer symptoms and their AHI is progressively decreasing.

If your AHI was stable, but is suddenly increasing over the past few days or weeks, you should report this to your sleep specialist.

Causes of rising AHI
AHIs fluctuating between 1–5 is normal and still within a safe range. If your nightly AHIs are rising above what’s considered safe, you may be experiencing:

Mask leak: If air is escaping your CPAP mask, you’re not getting all the air pressure you need to keep your airway open. The three most common causes of mask leak are a poorly fitting mask, inadequate cleaning or mouth leak (often experienced by patients on bilevel machines and mouth breathers currently using a nasal pillows or nasal mask).

Mask off events: It’s common for some people to remove their mask during the night, either consciously or unconsciously, due to the initial foreign feeling or discomfort of wearing a mask. If your CPAP machine is reporting this happening or you suspect that it is, don’t worry, but do talk to your doctor about ways to reduce these events.

Alcohol, medicine and other drugs: The periodic use of certain medication, alcohol or narcotics may cause your AHI to go up. Ask your doctor if anything you’re taking could be causing your fluctuation, and how you can compensate for it.

Central or complex sleep apnea: A rising AHI could also be a sign that while CPAP is treating your obstructive apneas, your brain might not always be telling your body to breathe. This can cause central sleep apneas, “central” because they’re caused by a dysfunction in the central nervous system, not a physical obstruction. Most newer CPAP machines will report if you’re experiencing central apneas, but it takes a specific type of machine to treat them. If your machine is reporting central apneas or you can’t identify what is causing your rising AHI and reverse the trend, talk to your doctor or equipment provider as soon as possible.

Adherence to continuous positive airway pressure (CPAP) therapy in men with obstructive sleep apnea (OSA) and erectile dysfunction (ED) significantly improves erections and sexual desire, a randomized controlled study has found. This finding should motivate men with both ED and OSA — a common co-occurrence — to use their prescribed CPAP machine nightly. Kerri Melehan, a doctoral student in Sydney, Australia’s Royal Prince Alfred Hospital and colleagues recruited 61 men with moderate or severe OSA (apneahypopnea index >20/h) and a 6-month or longer history of erectile dysfunction. They randomly assigned them to 12 weeks of treatment with CPAP. Subjects underwent polysomnography before and after treatment. The investigators measured the men’s number of sleep-related erections by recording and monitoring penile tumescence. Participants also reported subjective measures of their sexual function, relationship satisfaction, selfesteem, quality of life, sleepiness level, and satisfaction with ED treatment.

The 55 men who completed the trial had a mean age of 54 years, an average body mass and a mean serum testosterone level. They had an apneahypopnea index (AHI) of 43.9/h on average. In the CPAP vs sham-CPAP part of the study, there were 2 statistically significant findings for the entire group — those receiving actual CPAP had more erections during sleep (average of 4.1 vs 2.4) and better overall sexual satisfaction according to the study report. But the quality of erectile function did not significantly improve the findings showed.

For the subgroup of 20 CPAP recipients who adhered to at least 4 hours of treatment nightly, however, there were additional significant improvements in erectile function/quality and sexual desire as well as self-esteem, sleepiness, social function, and mental health, with reduced depression and stress.

“I can say with complete certainty that CPAP improves erectile dysfunction,” Ms Melehan said. “I think mental factors play a role because they feel more alive and awake.” In addition, she speculated that better oxygenation with CPAP may improve arterial stiffness. That is good news for men with OSA who also have ED

SUMMER VENDOR FAIR DRAWS CROWD

The Summer Support Group Meeting drew a large turnout for the annual Vendor Fair. Seven vendors showcased their latest in CPAP machines, masks, nasal pillows, oral appliances and services.

For those who missed the meeting, the following websites can bring you up to date on the latest;

Contra Costa Sleep Center: www.ccsleepcenter.com

Dental & Sleep Medicine Offices: www.drselleck.com

Fisher & Paykel: www.fphcare.com/sleep-apnea/

Respironics: www.healthcare.philips.com/us_en/homehealth/sleep/

ResMed: www.resmed.com/us/products/productspatients.html?nc=patients

N2Sleep: www.n2sleephomecare.com

Oxygen Plus: oxygenplusonline.com

THE JOURNEY THROUGH THE NIGHT

(excerpted from the Stanford Sleep Book)

Did you know just a regular night’s sleep had so many elements to it? Not many people know really about how complex sleep really is, or how many changes and events occur in just a single, ordinary night.

The following graph is a visual representations of how we generally progress through the different stages of sleep in a typical night.

The graphic representation above shows the transitions and relative amount of time spent in each stage of sleep in a typical night for a human adult. Notice that deep, slow-wave sleep is most prevalent at the start of the night, and that as the night progresses proportionally more and more time is spent in the rejuvenating REM sleep.

Sleep is entered through non-REM Stage 1, which usually persists for only a few minutes. During sleep onset Stage 1, sleep is easily interrupted by very low intensity stimuli, like a door closing or a gentle nudge.

In Stage 2 sleep the sleeper is more difficult to arouse; a stimulus that would produce wakefulness from Stage 1 will often not invoke a complete awakening. In most adults, Stage 4 of this first sleep cycle of the night is very deep sleep, and it is much harder to awaken the sleeper at this time than later in the night. Stage 4 typically continues for about 20 to 40 minutes, after which a series of body movements usually signals an “ascent” to lighter non-REM sleep stages.

A few minutes of Stage 3 may occur, or there may be a direct transition to Stage 2 sleep. After 5 or 10 minutes, the first period of REM sleep appears. This first REM episode of the night is often quite shortlived, usually lasting between 1 to 10 minutes.

The end of a REM episode and the transition to non-REM stages of sleep may be associated with some body movement, and a very brief arousal; or the transition may occur with no movements at all and no arousal. Often there is a change in body position such as a rolling over or a series of smaller adjustments. Throughout the night Non-REM and REM sleep continue to alternate.

The duration of the first sleep cycle–from sleep onset to the end of the first REM episode–is typically 60 to 90 minutes.

In the second sleep cycle, there is less Stage 4 and more Stage 2 sleep. The REM portion of the second cycle is a little longer than the first, usually around 10 to 20 minutes. The duration of the second sleep cycle, measured from the end of the first REM sleep period to the end of the second, is generally longer than the first, averaging 100 to 110 minutes.

In the third REM sleep period and beyond, Stages 3 and 4 are usually entirely absent or present in very small amounts; the non-REM portion of these cycles is almost entirely Stage 2 sleep. REM episodes tend to become longer in later cycles–the fourth or fifth REM episode typically lasts 30 to 45 minutes–leaving room for some serious dreaming time towards the end of the night.

Brief episodes of wakefulness tend to occur in later cycles, generally in association with transitions between Stage 2 and REM sleep, but these brief arousals are usually not remembered in the morning.

In summary, a night of sleep is characterized by a cyclic alternation of non-REM sleep and REM sleep. The average period of this cycle is typically 90 minutes. The first third of the night is usually considered the deepest sleep. REM sleep and Stage 2 predominate in the last third of the night.

SLEEP & FOOD CRAVING

( courtesy of United Healthcare newsletter )

A study funded by the National Institute of Health found that sleep patterns are linked to food cravings. Subjects who got only 4 hours of sleep each night reported a 23% increase in food cravings, especially for high fat, sweet and salty foods.

A “Couple” of Sleep Problems

(From the National Sleep Foundation)

By the time a couple has been together 20 years, they’ll have spent over 50,000 hours (roughly six to seven years) together in their bed. You’d think they’d have everything worked out by then . . . . Yet an estimated 23 percent of U.S. couples sleep apart, according to a survey conducted by the National Sleep Foundation. A survey of builders and architects reports an up-tick in the requests for dual master bedrooms!

For the other 77 percent of couples that do sleep together, the National Sleep Foundation survey indicates that one partner loses an average of 49 minutes of sleep per nightdue to some disruptive behavior, such as snoring, tossing and turning, watching TV, or preferring a warmer or cooler room.

Yet despite this, many psychologists warn that sleeping apart might not be a good solution to sleep issues. They believe that sleeping comfortably with your partner is an essential component of a healthy relationship. So before resorting to separate beds or bedrooms, it’s important to identify and attempt to resolve those potentially disruptive conflicts, even before they occur.

To put it in perspective, most marriages in the United States today start when the couples are in their mid to late twenties— and have therefore spent about a quarter of a century developing their own personal sleep habits and routines. There is an initial period of unlearning and relearning when it comes to sharing the bedroom, and for a while there is relative calm.

But as life progresses, our sleep patterns and habits slowly transform. We change careers, have children, gain weight, get pets. We age. And as we do, we may begin to snore, sleep warm, develop aches and pains, sleep more lightly and wake more frequently.We age at different rates, and men and women age uniquely, introducing potential conflicts in bed. The good news: most of these new “incompatibilities” are easily addressed once they are acknowledged and targeted. In the end, the real goal is simply to improve everybody’s sleep quality. Solving the “offender’s” issue will allow both partners to sleep better. If one simply traipses off to another bedroom without addressing the real problem, there could be unresolved consequences for one or both of you.

Subtle changes in sleeping habits or bedtime routines could help. Sleep accessories such as eye masks, ear plugs or sound machines have helped many. New bedding technologies can solve temperature disputes or disturbances from motion created by tossing and turning.

Finally, the solution may be something more involved. Millions of Americans have developed sleep disorders that require medical intervention. Any serious unresolved sleep issue should be discussed with your primary healthcare provider. After all, it’s about improving everyone’s sleep.

PAT McBRIDE TALKS ABOUT INSOMNIA

Pat McBride spoke to the last AWAKE meeting on Oct17th. She reviewed many of the issues surrounding insomnia. As a specialist in the dental treatment of sleep apnea, a board member of the Physicological Dentistry and Medicine Association, and Dental Sleep Medicine Consulting and Practice Management, she noted that Insomina is the most common complaint encountered in the field of sleep medicine. In any one year 1/3 of the adult population reports difficulty in sleeping and about 4% take some sort of sleep medication. Some individuals become distraught from unrealistic expectations as to how much sleep they should achieve. The patterns vary; 1) Prolonged time to fall asleep, 2)Awakening the middle of the night, and 3) early morning awakening.

There are two types of insomnia; primary and secondary.

Primary insomnia means a person is having problems that are not directly associated with any other health condition or issue.

Secondary Insomnia does have multiple causes and can be categorized as:

1. Medical conditions – pulmonary, cardiac, arthritis, gastrointestinal, nervous system
2. Psychiatric – dementia, depression, anxiety, stress
3. Sleep disorders – sleep apnea, sleep disordered breathing, periodic leg movements
4. Psychosocial – retirement, isolation, loneliness, bereavement, lack of physical activity
5. Circadian Rhythm Shifts – age related changes, shift work
6. Can result from other medications, foods, beverages
7. Environmental factors – temperature, noise, light
8. Poor sleep hygiene

Underling conditions must first be treated and stabilized, and if insomnia persists then sleep hygiene, behavioral therapy, counseling, or medications can be used. If no underling cause is identified then insomnia is described as Primary Insomnia. Insomnia is usually intermittent and unpredictable on any given night. It can be transient lasting only a few weeks or it can be chronic and go on for years.

There are daytime consequences of insomnia, such as, excessive drowsiness, impaired job performance, difficulties with concentration, memory, attention, problem solving, vitality, emotional stability, and increased reaction times, depression, absenteeism, auto accidents.

Insomnia also varies in how long it lasts and how often it occurs. It can be short-term (acute insomnia) or can last a long time (chronic insomnia). It can also come and go, with periods of time when a person has no sleep problems. Acute insomnia can last from one night to a few weeks. Insomnia is called chronic when a person has insomnia at least three nights a week for a month or longer.

*Causes of acute insomnia can include: Significant life stress, job loss or change, death of a loved one, divorce, moving) Illness, Emotional or physical discomfort, Environmental factors like noise, light, or extreme temperatures (hot or cold) that interfere with sleep. Some medications, Interferences in normal sleep schedule (jet lag or switching from a day to night shift,)

*Causes of chronic insomnia include:
• Depression and/or anxiety
• Chronic stress
• Pain or discomfort at night

Acute insomnia may not require treatment. Mild insomnia often can be prevented or cured by practicing good sleep habits If your insomnia makes it hard for you to function during the day because you are sleepy and tired, your health care provider may prescribe sleeping pills for a limited time. Rapid onset, short-acting drugs can help you avoid effects such as drowsiness the following day. Avoid using over-the-counter sleeping pills for insomnia, because they may have undesired side effects and tend to lose their effectiveness over time.

Treatment for chronic insomnia includes first treating any underlying conditions or health problems that are causing the insomnia. If insomnia continues, your health care provider may suggest behavioral therapy. Behavioral approaches help you to change behaviors that may worsen insomnia and to learn new behaviors to promote sleep. Techniques such as relaxation exercises, sleep restriction therapy, and reconditioning may be useful. Good sleep habits, also called sleep hygiene, can help you get a good night’s sleep and beat insomnia.

Here are some tips:
– Try to go to sleep at the same time each night and get up at the same time each morning.
– Try not to take naps during the day, because naps may make you less sleepy at night.
-Avoid caffeine, nicotine, and alcohol late in the day. Caffeine and nicotine are stimulants from falling asleep.
– Alcohol can cause waking in the night and interferes with sleep quality.
– Get regular exercise. Try not to exercise close to bedtime, because it may stimulate you and make it hard to fall asleep. Experts suggest not exercising for at least three to four hours before the time you go to sleep.
– Don’t eat a heavy meal late in the day. A light snack before bedtime, however, may help you sleep.
-Make your bedroom comfortable. Be sure that it is dark, quiet, and not too warm or too cold. If light is a problem, try a sleeping mask. If noise is a problem, try earplugs, a fan, or a “white noise” machine to cover up the sounds.
– Follow a routine to help you relax before sleep. Read a book, listen to music, or take a bath.
– Avoid using your bed for anything other than sleep or sex.
– If you can’t fall asleep and don’t feel that is not overly stimulating until you feel sleepy.
– If you find yourself lying awake worrying about things, try making a to-do list before you go to bed. This may help you to not focus on those worries overnight.

CPAP CAN IMPROVE YOUR LOOKS

(WebMD News, Sept. 13, 2013)

Treatment for sleep apnea may do more than improve your sleep and health: It could help you look better, according to a new study.

The study included 20 middle-aged sleep apnea patients whose facial appearance was rated before and after they started using a treatment called continuous positive airway pressure (CPAP), which helps keep the airway open by providing a stream of air through a mask that is worn during sleep.

Improvements in the patients’ faces were noted just a few months after they started using CPAP, according to the study published in the Journal of Clinical Sleep Medicine.

These changes included: looking more alert, more youthful, more attractive, having less-puffy foreheads and less-red faces.

The findings need to be confirmed in larger studies, the researchers said. They decided to conduct their study because sleep center staff often noted improvements in patients’ faces after they began using CPAP.

What Are Naps?

By Brandon Peters, M.D.

(Dr. Peters is a neurology-trained sleep medicine specialist who currently practices in Novato, CA and serves as adjunct clinical faculty at Stanford University.)

A nap is a short period of sleep that typically occurs during the day. Children may take frequent naps as their nighttime sleep is less consolidated. As we get older, we do most of our sleeping at night. Nevertheless, we typically have a strong desire to take a nap in the early afternoon.

Reasons to Nap

There are plenty of reasons to get a little extra sleep in the form of a nap. The most obvious reason for a nap is that you simply are not getting enough sleep at night. This may be a temporary inadequacy or a chronic issue. It may be helpful to determine how much sleep you need to see if this is a likely contributor.

There may be other reasons that you have excessive daytime sleepiness and need a little extra sleep in the form of a nap. This could be due to any of the sleep disorders that can cause sleepiness, including sleep apnea, narcolepsy, and insomnia.

Napping Options and Benefits

People will commonly say that they “power nap.” The implication is that a short amount of time spent sleeping (15 to 20 minutes) can revitalize and recharge. Assuming that you are able to fall asleep fairly quickly, you may be expected to enter into the lighter stages of sleep (either stage 1 or stage 2). This can be refreshing, but it may not give you the brain boost you desire.

More prolonged naps seem to have favorable consequences, improving memory and creativity. When naps last 30 to 60 minutes, you are more likely to enter into deep or slow-wave sleep. It is thought that even longer naps (up to 90 minutes or more) can enhance creative problem solving. Studies have consistently shown that naps can improve alertness and motor performance. Naps can furthermore reduce stress and even decrease your risk of heart disease.

“Everything you need to know about CPAP – But were afraid to ask!”

founders of the Sleep Apnea Patient Support Group 19 years ago), ably assisted by Bill Stoll of Timberlake Respiratory Care gave an excellent presentation to the Support Group at the spring meeting on “Everything you need to know about PAP.”

Lori traced the history of CPAP therapy from what was originally called the “Pickwickian Syndrome” (named after “Joe” in the Charles Dicken’s novel, “The Pickwick Papers” who fell asleep in almost any situation) up through the development of PAP (Positive Airway Pressure). Lori also covered the variations of PAP and their specialized uses. This was followed by an informative Q & A session.

HIGHER RISK SLEEP APNEA WITH USE OF OPIOID PAIN MEDS

(from MedicalNewsToday.com)

Opioid-based pain medications1 may cause sleep apnea, according to an article in the September issue of Pain Medicine, the journal of the American Academy of Pain Medicine.

“We found that sleep-disordered breathing was common when chronic pain patients took prescribed opioids,” explains lead author Lynn R. Webster, MD, from Lifetree Clinical Research and Pain Clinic in Salt Lake City, Utah. “We also found a direct dose-response relationship between central sleep apnea and methadone and benzodiazepines2 an association which had not been previously reported.”

Opioids, effective medications for chronic pain treatment, are often used for cancer patients, but are now gaining widespread acceptance as long-term therapy for chronic pain unrelated to cancer. An increasing number of patients with nonmalignant chronic pain are receiving around-the-clock pain relief through opioid therapy.

The researchers studied sleep lab data on 140 patients taking around-the-clock opioid therapy for chronic pain to assess the potential and prevalence sleep apnea in opioid treated pain patients. All patients were on opioid therapy for at least six months with stable dosing for at least four weeks.

The investigators say that their results show a higher than expected prevalence of sleep disordered breathing in opioid treated chronic pain patients. Obstructive and central sleep apnea syndromes occurred in the studied population at a far greater rate (75%) than is observed in the general population, where obstructive sleep apnea is known to be underdiagnosed but has been estimated at roughly 2% to 4%. Central sleep apnea is estimated at 5% in people older than 65 years and from 1.5% to 5% in men less than 65 years old. People who stop breathing during sleep because of faulty brain control have central sleep apnea as opposed to obstructive apnea, which is triggered by obesity and/or other health problems and accompanied by loud snoring.

The investigators comment that the absence of crescendo-decrescendo breath size commonly associated with central sleep apnea suggests that the central sleep apnea mechanism is different for people taking opioids than the general public. They suggest it could be related to the direct effects of opioids on the part of the brain that controls respiration.

The authors also note that if opioid medications increase sleep apnea risk as their research suggests, then chronic pain patients who are prescribed opioids have a higher risk of contracting sleep apnea.

“The challenge is to monitor and adjust medications for maximum safety, not to eliminate them at the expense of pain management,” Dr. Webster concludes.

1 The American Academy of Family Physicians notes that opioid drugs include those  produced for pharmaceutical purposes and those for recreational purposes. For example, opium and heroin are street opioid drugs. Other opioid drugs, such as codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxycontin, oxymorphone, paregoric, sufentanil and tramadol, have medical purposes.
2 http://wikipedia.org/wiki/List_of_benzodiazepines

IMPORTANT CHANGE IN HOW YOU GET CPAP SUPPLIES

Effective July 1, 2013 Medicare has changed the manner in which those on “Original Medicare” obtain CPAP equipment and supplies if you live in certain areas, In order to receive Medicare reimbursement you need to obtain these supplies from a “Medicare – Contract Supplier.” The schedule for replacement of CPAP equipment and supplies remains unchanged only the manner in which you receive them. Information regarding this program was mailed to eligible Medicare patients. If you did not receive the material in the mail of have questions go to www.Medicare.gov/supplier and enter your ZIP code or call 1-800-633-4227.

Trauma and Sleep

(from National Sleep foundation)

Stress from a traumatic event can often lead to a variety of sleep problems. The result can be insomnia, bad dreams, and daytime fatigue caused by sleep disturbance. Some people with sleep problems and anxiety have posttraumatic stress disorder, or PTSD. PTSD is a reaction to a traumatic stressful event resulting in a feeling of a loss of control and an inability to help yourself in a bad situation. It’s often experienced by people who are in situations that range from combat to rape, but it can be caused by a variety of events.

When the body is overstimulated, the brain is flooded with neurochemicals that keep us awake, such as epinephrine and adrenaline, making it difficult to wind down at the end of the day. The neurochemicals remain present in the brain and can interrupt your normal sleep cycle. The following are common sleep problems following a trauma:

Flashbacks and troubling thoughts can make falling asleep difficult.

The victim might feel the need to maintain a high level of vigilance, which can make sleep difficult.

For those who experience violent situations, nighttime and darkness can, in and of themselves, bring about added anxiety and restlessness.

Taking naps during the day might be helpful, but, if overdone, can also interfere with your efforts to sleep through the night.

Once asleep, nightmares can frighten a survivor back to consciousness, and getting back to sleep can be very difficult.

COPING
For those who are experiencing temporary sleep problems, there are a number of things you need to know which can help with insomnia, bad dreams, and daytime fatigue. Sleep experts recommend trying to reduce feelings of stress, especially before bedtime. Don’t watch the news right before going to bed. Avoid coffee in the afternoon and evening. Take a warm bath or soak in a hot tub before bedtime. If sleep problems persist, see your doctor, who can prescribe medications that will help you sleep but won’t make you groggy in the morning. Here are some additional tips that may prove helpful:

Sleep in a location where you will feel most rested and safe. While the bedroom is optimal, it may not be possible to rest there soon after the trauma if you experienced violence in that room.

Create an environment in which you can sleep well. It should be safe, quiet, cool and comfortable. While it often helps to sleep in a dark room, if keeping a nightlight on helps bring about a more safe feeling, then consider keeping the room dimly lit.
• Engage in a relaxing, non-alerting activity at bedtime such as reading or listening to music. For some people, soaking in a warm bath or hot tub can be helpful. Avoid activities that are mentally or physically stimulating, including discussion about your violent experience, right before bedtime.
• Do not eat or drink too much before bedtime and recognize the negative role that alcohol can have on your sleep.
• Rest when you need to rest. It is common to feel exhausted after a violent trauma, so you may need more rest or to rest differently during this time. Relaxing and resting for brief times throughout the day and taking short naps (15-45 minutes) may help.
• Go to bed when you feel ready to sleep. Try not to force sleep, which can add to the pressure of wanting to get to sleep. Developing the harmful habit of lying in bed awake for long periods when you want to sleep is counter-productive.

 

DRUG MAY AID SLEEP APNEA AT ALTITUDE

(The following article may be of interest to those who have occasion to be at altitudes above 5000′)

People with sleep apnea can safely travel to high altitudes with the help of a diuretic and a commonly used breathing device, a new study from Switzerland suggests.

Researchers found acetazolamide (sold as Diamox), which is already used to treat mountain sickness, improved overnight oxygen levels among people with the sleep disorder who spent time above 5,000 feet. Because there is less oxygen in the air at high altitude, nighttime breathing symptoms may get worse far above sea level. However, there aren’t any standard recommendations for mountain travelers with sleep apnea, according to Dr. Konrad Bloch, who worked on the new study.

“Physicians had no scientific evidence to counsel the patients,” Bloch, from the University Hospital of Zurich, told Reuters Health.

To try to provide some guidance, his team sent 51 people with sleep apnea – all of whom lived at low altitude – to resorts in the Swiss Alps as high as 8,497 feet on two different trips.

Each time, the volunteers used a breathing device commonly prescribed to people with sleep apnea, called continuous positive airway pressure therapy, or CPAP, at night. On one trip, participants also took three 250- milligram doses of acetazolamide each day. On the other, they were given drug-free placebo pill.

Along with being a diuretic, acetazolamide also triggers more frequent breathing. Bloch and his colleagues found participants’ average oxygen saturation overnight – a measure of sleep apnea severity – was better among the acetazolamide group, at 91 percent versus 89 percent in the placebo group at the highest altitude. (Normal oxygen saturation is between 97 and 99 percent.)

People taking acetazolamide also stopped breathing fewer times during the night than those taking the placebo pills, the research team reported Tuesday in the Journal of the American Medical Association.

With the type of CPAP used here, called autoCPAP, a computer controls air pressure flowing through the breathing mask. For standard CPAP – which is more common in the United States – pressure is calibrated in a sleep lab and doesn’t change based on nightly variation.

Most of the study volunteers were moderately obese men. Any related conditions they had – such as diabetes or high blood pressure – were stable before the study.

WATCH OUT FOR SIDE EFFECTS
Bloch said acetazolamide, which requires a prescription, “is not a harmless drug” because it alters water and salt content in the body. Some people in the study had side effects such as burning, numbness or tingling – and others complained about the drug’s taste.

For patients with heart or kidney disease in addition to sleep apnea, acetazolamide could lead to more serious complications – by making them pee too much, said Dr. Seva Polotsky, a sleep apnea researcher from Johns Hopkins University School of Medicine in Baltimore.

“I think it’s really beneficial. Having said that, you have to be careful with this drug,” Polotsky, who wasn’t involved in the new study.

“I would definitely check with a doctor and approach it very carefully.”

The new research was partially funded by a grant from Philips Respironics, which markets sleep systems such as CPAP devices. Drs.Bloch and Polotsky both recommended anyone traveling at altitude ascend slowly and take time to acclimatize along the way. “This is a recommendation that is important for everyone, but especially those that have a breathing problem,” Bloch said.

SOURCE: Journal of the American Medical Association, online Dec 11, 2012

SHOULD YOU HAVE A BACK-UP CPAP MACHINE?

The answer is emphatically YES!

Here is why: By the time that your sleep apnea gets bad enough that you take action to correct it, you’ve probably been suffering from it for 20 or more years. Obstructive Sleep Apnea is insidiously slow. You think your are sleeping well but your bed partner can tell you different. Your friends and hunting buddies can tell you different. Snoring, not breathing for up to a minute, chocking, gasping for air, it doesn’t bother you but it bothers them. You sleep the night away but they don’t.

Even though you sleep the night away, you don’t get the rest your body needs to repair itself. CPAP therapy restores normal breathing while you sleep. It keeps your upper airway open allowing you to breath normally. It allows you to go into the deeper stages of sleep allowing your anatomical functions to slow down and do the necessary repair work. After using CPAP for a while, your system returns to it’s normal functioning. The stresses placed on the heart and lungs is eliminated. You get back to a near normal state.

Suddenly, your CPAP machine or your nasal interface quits or breaks. You can’t use your CPAP machine because it is showing SERVICE REQUIRED or and ER (error) code in the LED window. It won’t run.

Can you get along without it? Sure! All you need to do is sleep setting up. As you find out on night one, that doesn’t work out too well. The next night you sleep on your stomach. That doesn’t work out either because it is very uncomfortable.

The third night you keep jerking yourself awake because you are not breathing properly, the apnea is waking you up or your snoring is waking you up. You are not sleeping. The next day you are tired, sleepy, can’t concentrate, have a hard time staying awake while driving, watching television or trying to read the daily paper. Your apnea is back, full blown and trying to kill you. Suddenly the stresses that cause heart attacks and strokes is much higher because your system had acclimate to a near normal stress level, thanks to the CPAP therapy. With out the CPAP you are at a much If you had a back up CPAP machine setting in the closet, when the old machine quits, within 10 to 15 minutes you could be back to sleeping like a baby. You and everybody else would be happy. Get a back-up CPAP machine now. They are not that expensive. This is affordable insurance, even setting in the closet!

SOURCE: www.cpapman.com/newsletter

Alzheimerʼs Disease and Dementia

Alzheimer’s disease (AD) is a brain disorder that affects a person’s thoughts, memory, speech, and ability to carry out daily activities. There is a loss of brain tissue that leads to deterioration of mental abilities and may also disrupt the sleep/wake cycle, which may cause sleep problems, nighttime wandering, and agitation.

Symptoms of AD develop slowly, usually beginning with short term memory problems. Over time, patients gradually lose more and more of their mental capabilities. For example, they may have difficulty remembering people or events and then lose the ability to do everyday tasks such as cooking, cleaning, and bathing. Eventually, AD patients may not be able to recognize loved ones, speak, or think clearly. Additional symptoms of AD include: Incontinence; speech problems; an inability to dress, or groom oneself; wandering and getting lost; losing items; and depression.

Patients in the early stages of AD may sleep more than usual or wake up disoriented. As the disease progresses, patients may begin to sleep during the day and awaken frequently throughout the night. Patients with more advanced AD rarely sleep for long periods. Rather, they doze irregularly throughout the day and night. Because caregivers are likely to be asleep during the night when AD patients are active, sleep/wake disruptions can be a dangerous problem for AD sufferers. In addition, AD patients who do not get enough sleep are more likely to suffer from agitation.

A feature of AD is “sundowning,” a term used to describe an increase in agitated behavior that occurs in the evening. This increased agitation may be explained by sleepiness or it may be that agitated behavior is more troublesome to caregivers after sun down. Whatever their causes, agitation and sleep problems result in severe stress for caregivers and are among the top reasons AD patients are given care in nursing homes instead of at home.

Alzheimer’s disease is not a normal part of aging but the risk of developing it goes up with age. It usually begins after age 60 and the risk nearly doubles with every 5 years of age after age 60. The number of Alzheimer’s patients is expected to increase dramatically in the coming years.

There is no cure for AD, but there are behavioral and drug therapies that may slow its progression and treat its symptoms. For example, cholinesterase inhibitors are medications used to treat mild to moderate AD (Aricept). They work by blocking the action of an enzyme that breaks down acetylcholine, a chemical which is essential to brain function. In addition, a drug called memantine is used to treat moderate to severe AD (Namenda). It works by regulating glutamate, a chemical in the brain that is important to learning and memory. AD patients may also benefit from antidepressant, antipsychotic, and sedating medications.

The National Institute on Aging at the National Institutes of Health identifies many forms of dementia, all of which have many of the same effects as Alzheimer’s disease. AD is the most prevalent form of dementia, though the second leading cause of impaired cognitive function in older adults is multi-infarct dementia which is actually caused by a series of often imperceptible strokes. Some forms of dementia may be cured or managed if accurately diagnosed and treated. That is why it is important to actively seek out answers to signs of memory loss.

Coping with AD:
• Create an ideal sleep environment
• Keep a regular sleep/wake schedule
• Get into bright light soon after waking
• Keep lighting dim as bedtime approaches
• Create simple routines for accomplishing everyday tasks
• Create a safe environment – keep dangerous items out of reach
• Use labels and reminder notes to help accomplish daily tasks such as dressing and food preparations
• Get some form of exercise every day