Getting a Good Night's Sleep -- Michael Breus, PhD -- 03/25/03
By Michael Breus
It could be the international conflict, it could be the economy, but you haven't kept your date with the sandman in quite some time. Or maybe it's your child suffering in these tense times. We received tips for a peaceful night from WebMD's sleep disorders expert, Michael Breus, PhD.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome one again, Dr. Mike. Here's our first question.
Member: Does a CPAP require routine maintenance other than cleaning? How often should it be done? Is there a cost for it?
Breus: Excellent question. When using a CPAP machine, it is essential to have it cleaned once a week using a solution of one part vinegar, three parts water. However, maintenance on the machine itself should be done at least once every six months, by either the home healthcare company or the sleep specialist's office. There may be a small incidental charge depending upon which insurance company is covering your CPAP machine.
Member: When you say that the CPAP should be cleaned, are you referring to the hoses/mask or is there something I'm missing?
Breus: The vinegar/water solution is for the hoses and mask. While the once every six month maintenance is for the blower itself.
Member: I use a CPAP due to sleep apnea and began using a humidifier attachment this winter after five years without one. I've had multiple sinus problems since beginning with the humidifier. Is this commonly reported or is the stuffiness in my head likely not related to the humidifier use?
Breus: In general, we often use humidification in order to relieve congestion. However, if water is left in the humidifier for extended periods of time, bacteria may grow and potentially cause sinus infection. Therefore, it would be worthwhile to empty the humidifier water every morning, as well as see your doctor about the possibility of congestion-related problems such as sinusitis or allergies.
Member: For about four years now I have been having difficulty staying asleep throughout the night. I don't have a problem falling asleep, just staying asleep. On average, I wake up about three to four times a night. My doctor is currently prescribing me 300 mg of Trazodone each night and I am still waking up. I would love to get a good night's sleep without waking up. I have no idea what it might be due to, and my doctors are having a tough time finding out also. I am only 24 years of age and the doctors say that my problem is unusual for someone of my age. I went through a sleep study a few moths ago and eliminated that as a possibility. I have also been through asthma tests, neurologists, and have tried Ambien, Xanax, Risperdol, Elavil, and currently Trazodone and nothing is working. I you can address my question and possibly give me some advice. Thanks a lot.
Breus: Based on your previous medication history, it sounds as though you have tried several different things in an attempt to relieve your insomnia. It may be time to see an insomnia/sleep specialist to have a more focused approach towards your sleep problem. It is good that you have not had a positive sleep study, as that will rule out many things. As far as medications that you have not tried, you may want to consider asking your physician about Seroquel, Klonopin, or other benzodiazepine-hypnotics.
Member: I am on Klonipin but I use that for my anxiety. I am actually going to the psychiatrist tomorrow to have my meds changed.
Breus: One thing you may want to ask your psychiatrist is if it would be possible to take the Klonipin in the evenings to help with sleep.
Member: I have had a problem sleeping at night when it's dark due to terrible nightmares since I was young. I am 35 years old and still have same problem. My doctor gives me meds for sleep but they rarely work. I stay awake all night and sleep the days away and get very angry at myself, which adds to depression. It's a vicious cycle; do you have any suggestions?
Breus: This is a very difficult situation to deal with. To date, there are several potential nightmare treatments, some of which have been quite effective. There are many medications that could be causing nightmares, and if you are currently taking any medication you may want to ask your physician to review these medications as a possible cause of your nightmares. If this does not help determine the cause of your nightmares, you may want to consider speaking with a sleep specialist about REM-depressing medications including tricyclic antidepressants and SSRIs.
If these medications do not work, there is an old technique that has been recently found to work quite well called imagery rehearsal. Dr. Barry Kracow has recently created a nightmare treatment protocol that may be worth investigating. His web site is nightmaretreatment.com.
Member: I am on a lot of pain medication -- are they a contributor?
Breus: It's certainly possible. However, it would be important to have the prescribing doctor review the medication for nightmares.
Member: I have had difficulty sleeping for about 10 years and have used medication for about two years off and on. I can't fall asleep. I have tried both Trazodone and Ambien. Last night I took my Ambien and it took about one and a half hours to fall asleep and then I only slept about four hours. Is it possible to find a drug that can help me establish a regular sleeping pattern that could then be continued without meds?
Breus: Yes, there is. However, you are going to require the help of a board certified sleep specialist who can use pharmacotherapy as well as behavioral techniques. One can best be found at an AASM accredited sleep lab. If you have a hard time finding an accredited sleep lab, go to the web and find the American Academy of Sleep Medicines web site (www.aasmnet.org). Go to patient resources and find a sleep center. On it there is a listing of accredited labs in each state.
Member: My boyfriend has a terrible snoring problem. We have tried over-the-counter snore relievers and breathing strips and homeopathic solutions to no avail. I have such problems sleeping anyways and when he is snoring it makes my attempts to sleep impossible. I end up falling asleep on couch in the a.m. from sheer exhaustion.
Breus: It sounds like your boyfriend needs a sleep study to determine whether or not he has obstructive sleep apnea. There are many treatments for both apnea and the snoring other than leaving the room and earplugs. You should try to convince him of the potential dangers of untreated sleep apnea, which may include high blood pressure, heart attack, and stroke. Best of luck.
Member: I don't have problems falling asleep. I average approximately six to seven hours of sleep per night; however, I still feel tired and sleepy during the day. I am 35 years old, exercise regularly, and am in good shape. I don't use any medication. Is there anything I can do to remedy this problem?
Breus: There are several possibilities that may be preventing you from having effective sleep. The first thing to do is check your personal sleep hygiene. You may want to review in your mind whether any of these substances are in your body that can cause sleep fragmentation. These may include:
Most people do not realize that caffeine has a half-life of approximately 12 hours, and may be able to affect your sleep long after it's been ingested. The next thing to think about is your sleep environment. For example, any individuals who sleep with a noisy bed partner, pets, or in a room that is not conducive to good sleep. Making sure that your environment is "sleep friendly" may go a long way to improving your sleep at night, which will make you more alert during the day.
If both of these fail, it may be worthwhile to have a full physical exam, commenting to your doctor about your lethargy and possible fatigue during the day. If after all of this there are no reasons pointing to your tiredness during the day seeing a sleep specialist would be the route to take.
Member: My fiancée has a horrible time sleeping at night. She is starting to interrupt my sleep also at night. She has been to so many doctors and through so many tests, no one can figure out what her problem is. She has been on a lot of sleeping medications and none of them seem to help. What can she do?
Breus: It sounds like she has been searching for an answer to sleep difficulties for quite some time. If she has not as of yet seen a board certified sleep specialist, I think now would be the time. As I remarked earlier, these doctors can be found on the American Academy of Sleep Medicine's web site.
Member: I checked out the American Academy of Sleep Medicine's web site and looked for a local center. I took my fiancée to one of those centers about three months ago. It was in Allentown, Penn. They were not any help. She stayed there overnight while they monitored her and came up with nothing. They suggested she see her asthma doctor because that might be a cause. Her asthma is under control, though. She did see the pulmonary doctor and he said she was fine. Are there any other options? Any thing else she can do?
Breus: You need to re-contact the sleep disorder center and ask to speak with the board certified sleep doctor and request information on treatments for insomnia, including behavioral measures, because basically this doctor should know and understand not just apnea but insomnia as well. If no one is helpful, contacting other local centers and speaking with other board certified doctors may be necessary.
Member: I have been taking Tylenol PM for years. I don't know any other way to fall asleep. I am now nine weeks pregnant and still taking Tylenol PM. What can I do? I've tried falling asleep without it but I just end up tossing and turning all night. Please help.
Breus: Welcome to pregnancy. It is not healthy for you or your unborn child to be taking this drug nightly. Although it is something that can be taken under a doctor's advice during pregnancy, every night can cause significant harm. While pregnant, your sleep will be significantly disrupted during the first trimester, oftentimes due to restlessness, and then again in the third trimester due to an inability to find a comfortable position. I wish I had a better answer for you, but the Tylenol PM must stop and your difficulty sleeping will likely continue throughout the pregnancy. Good luck.
Member: What is the best type of mattress on the market today? Are the air mattress or therapedic ones any good?
Breus: Your question is a good one, but not one with must scientific testing having been done. To date, there is no head-to-head comparison studies that have not been performed by the mattress companies themselves. Thus, an unbiased opinion is unlikely. I do believe, however, that there is some merit to the mattress systems where each individual can set the firmness for their side of the mattress to allow for a better night's rest.
Member: What's the cause of insomnia when there are no other stresses going on other than multiple sclerosis? I feel like I could sleep for a month, and need to, but it just never happens!
Breus: That's an excellent question, but quite difficult to answer. Understanding sleep pathology surround MS has not been well defined. We do, however, know that due to nerve conduction abnormalities in MS patients they will show fragmented sleep architecture and poor quality sleep, which in turn can cause somnolence during the day. Insomnia can be characteristic of MS but since it is not always considered one, the research to date is inconclusive.
Member: What is the cause of when I lay back in my recliner for a nap and when I start to dose off my body will jerk or jump and awake me?
Breus: This is called hypnic jerk, or sleep start, which is quite common when somebody has significant sleep deprivation. It is a good sign to tell whether or not you are well rested. If you have these on a regular basis, chances are you may not be well rested, in which case it may be important to sleep to your doctor or a certified sleep specialist.
Member: When I am asleep I bite my tongue. It wakes me up and it bleeds and hurts for days. I just need an expert opinion on what to do.
Breus: There are several reasons why tongue-biting potentially occurs. One of the most likely is seizure. If someone bites to the point of bleeding, it would be important to have a full sleep study and review from a neurologist surrounding these problems.
Member: I'm 18 years old and I am always tired. I could sleep and I will still be tired during the day. I usually have trouble going to sleep. When I sleep I could sleep like eleven hours wake up and still be tired. I even take a multi-vitamin to help me. But this is how it's always been. Am I lacking iron?
Breus: There is a possibility that anemia could cause your sleepiness. However, it is highly unlikely. What is more likely is one of two things: Either you are not getting enough sleep on a consistent basis and are sleep-deprived or you could have a sleep disorder, for example narcolepsy, which causes people to be somnolent during the day no matter how much sleep they get.
Member: I had a history of not sleeping very well -- I'd frequently wake up half way through the night and my mind was going. As result, I have been using 1 or 2 (25mg) antihistamine pills before going to bed for nearly 15 years now. It helps a lot. Do you see any problem with this?
Breus: Long-term use of antihistamines can cause problems down the road, not to mention masking true problems associated with sleep. It is usually best to understand underlying pathology and reasons why you require sleep medication to help actually treat the disorder.
Member: What are the symptoms of severe sleep deprivation?
Breus: Severe sleep deprivation can manifest itself as problems with thinking, memory, attention, and fatigue. In addition, sleep deprivation may cause morning headaches, slow reaction time, and difficulty driving. If you experience these symptoms, it is certainly worth speaking to your physician regarding your sleepiness.
Member: I was taking 200 mg of Serzone twice per day for nine months ending in November 2002. In one of your answers you indicated you no longer recommend Serzone as it can often cause later liver problems. What type of problems does it cause and what would be my probability of developing such problems?
Breus: Approximately six months ago, a black box recommendation came out on Serzone indicating the possibility of liver toxicity and failure with extended use for long periods of time, which means that your liver could at the worst case, stop functioning altogether. Although this is unlikely, the fact that the company came out with this recommendation would indicate that it is possible. In our practice, we no longer prescribe Serzone for this very reason. If you have been on Serzone for an extended period of time, I would request liver function tests to see if damage has occurred.
Member: What is the danger of long-term use of Ambien such as 10 mg nightly for 20 years?
Breus: To date, there is no empirical evidence for damage by Ambien in the long term. Anecdotally, our practice has seen several patients at 10 and 15-plus years on Ambien with no medical complications.
Member: Since I cannot tolerate sleeping with either style sleep mask for my sleep apnea, is there anything else I can do to help myself such as using a cool mist humidifier? Also, on the nights I can't fall asleep, my doctor told me to take a 100 mg tablet of Trazodone. This tablet was much too strong and left me like a zombie the next morning. I tried taking half of the tablet but that didn't even help me fall asleep. In the past I had taken 10 mg. diazepam but my doctor said diazepam is very bad for people with sleep apnea and to stop taking them. May I have your thoughts please?
Breus: Benodiazapines like diazepam can cause a worsening of sleep apnea. Therefore, I agree with your physician's recommendation to avoid this medication with your apnea. Ambien subsequently has no effect on respiratory drive and therefore can be used in patients with sleep apnea. There is a new form of sleep mask that has just become available on the market that is more of a canula-based mask called either "Spirits," or the "Nasal Aire," which may be easier to tolerate. However, using only a cool mist humidifier will not treat your apnea.
Member: I've recently had an at-home test for sleep apnea. The lowest saturation of 75% almost 52% of the night was spent with a saturation of less than 90% suggesting underlying cardiopulmonary disease and not sleep apnea. My question to you is what types of cardiopulmonary disease are most commonly related to this situation?
Breus: It could be anything from COPB to core pulmonale. However, having saturations that low may also be an indication of sleep apnea, thus treatment for underlying cardiopulmonary issues should also include a workup for sleep apnea.
Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Mike?
Breus: Thank you for your interest in sleep disorders. I had fun today answering your questions. But don't let that stop you. Feel free to ask questions on the message board. I answer all questions, but it may take me a little bit of time. Thanks again. Dr. Mike.
Moderator: Unfortunately, we are out of time. Thanks for joining us, members, and thanks to Michael Breus, PhD, for being our guest.
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