Insomnia || Be on the lookout for insomnia's secret cousin: untreated OSA

You can't sleep at night. You've taken every pill, and none of them work. You still get up several hours a night and have trouble falling back asleep. But you haven't had a sleep study yet.

Maybe it's time you had a sleep study.

It has been common practice to separate the majority of insomniacs from other sleep disordered patients and place them in the therapy/pharmacology track to treat their problems with sleeplessness. Overnight sleep studies are expensive and it has been thought that such a diagnostic test would not be the first course of action for someone who seemed to only suffer from insomnia.

However, a recent study published by the Mayo Clinic, led by physician Dr. Barry Krakow, discovered that many people being treated for insomnia, who had failed all pharmacological treatments, actually suffer from undiagnosed and untreated obstructive sleep apnea.

“We are used to seeing insomnia as a psychological condition, but in these drug-failure cases nearly all patients also suffered from a physical condition, obstructive sleep apnea,” said Dr. Krakow.

The study, published last September, observed over 1200 patients with chronic insomnia, 900 of which were using (and failing at) some kind of sleep aid. Those with prescription sleep aids seemed to suffer the most, interestingly, reporting more delayed sleep onset, more wakeful periods during the night and the lowest sleep efficiency, all of which are consistent with severe insomnia. Assessing over 900 of these patients via a sleep study using the most advanced respiratory technology revealed a mind-blowing 91 percent of them had a confirmed diagnosis of moderate to severe obstructive sleep apnea.

This is a huge finding, as many patients may now be prompted to have an overnight sleep study to determine the likelihood they have unresolved apnea, something not commonly done before with patients assumed to only have insomnia.

Dr. Krakow was asked, in a CHEST Physician interview, what made him think to study breathing patterns in insomnia patients who were not complaining of traditional OSA symptoms.

"We asked insomnia patients to tell us why they wake up and found that the causes they attribute to their awakenings are very different from what we see in the sleep lab. Fifty percent say it’s mental and 50 percent say it’s physical," he said. "They’ll also point to things after the fact, such as 'I woke up because my mind is racing' and then realize that the racing thoughts really emerged after the awakening. In the lab, however, breathing events were the most common cause of their awakenings."

It makes sense. Sleep apnea can perpetuate insomnia as it causes sleep fragmentation, which disrupts the sleep cycle with frequent awakenings. Patients awaken upon having apneic episodes but think they have insomnia or need to use the restroom. Frequently rising to urinate may also be a hallmark of  undiagnosed sleep apnea; when the body undergoes an apneic episode, and the patient awakens gasping for air (which they may or may not be consciously aware of), it sets off a chain of stress responses in the body which leads to signals of awakening, which prompt the body to empty the bladder, whether it is full or not.

Senior research investigator Victor Ulibarri also pointed out that “remarkably, greater than 70 percent of this patient population reported sleep breathing symptoms like snoring or gasping
during sleep and suffered from insomnia for an average of a decade, yet none of these patients had previously been evaluated or referred for sleep testing.”

This generates the concern that primary care physicians, who are the chief referring doctors for sleep studies, may not be asking enough of or the right questions during a general healthcare visit to discern whether the origin of a patient's potential insomnia is psychological or possibly physiological. It can also be hard to determine when sleep medications are failing, which can lead to significant problems with evaluating sleep problems on a timely basis when they are initially only linked to insomnia.

Dr. Krakow points out that “doctors may be confused or challenged in sorting out when patients need medication or an evaluation at a sleep medical center.”

Senior research investigator Natalia D. McIver warns that drugs are not always going to be the way a sleep problem is fixed. "Insomnia patients perplexed by their sleeplessness may steer doctors toward quick fixes with pills. But, when we show patients the importance of sleep breathing, they are eager to attempt effective sleep apnea treatments.”

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And they should be. Many medications used for sleep onset for insomniacs depress the respiratory system; if someone with a sleep-breathing disorder takes these drugs, they may in fact make their condition worse.

Ultimately, the research points to more expedited referrals of insomnia patients for sleep testing to rule out sleep breathing disorders so as to identify which patients truly benefit from therapies for apnea versus those who may do better on a sleep medication.

To learn more about the study and how it may impact insomnia and other sleep diagnoses in the future, please check out this video from the Mayo Clinic.


SOURCES

CHEST Physician || OSA and insomnia often share a bed
Mayo Clinic Sleep & Human Health Institute || Insomniacs Failing Drugs Suffer from Sleep Apnea [PDF]
Sleep Review: || A Missing Link: Dr Barry Krakow’s Research on Insomnia and SDB

Alternatives || Valerian, aka "Nature's Valium" -- safe to use, effective? You be the judge

Many people suffering from insomnia turn to alternative medications to help them to either fall asleep or to stay asleep. Valerian is frequently touted as a useful treatment for insomnia, but does it work? Here is a breakdown of Valerian based on information that everyone should consider before taking any kind of over-the-counter supplement. Also, Dr. Timothy Morgenthaler for the Mayo Clinic offers this excellent general advice for people interested in using Valerian as a sleep aid: "Product claims may be misleading. Be a smart consumer and do a little homework. Don't just rely on a product's marketing. Look for objective, research-based information to evaluate a product's claims."

What Valerian is

Botanical illustration of  Valeriana officinalis

Valerian is a flowering plant found in grassland regions. Its root and leaves has been used for centuries to provide relief for insomniacs, often combined with hops or lemon balm to achieve a mild sedative effect. Germany's version of the FDA has approved of Valerian as an effective mild sedative; the USDA lists Valerian as "Generally Recognized As Safe" (GRAS).

How it works
Though the science is inconclusive on how Valerian works, some research shows that it can increase the amount of GABA in the brain much in the same way that some common anti-anxiety drugs work. Endogenous GABA is a chemical component of the brain which regulates nerve cells and promotes calm. Valerian may provide a similar, if lighter, effect on brain chemistry as Xanax or Valium. Some research points to using Valerian to help improve the sleep quality of people who are tapering their use of prescription sleeping pills. Other research points to the possibility that Valerian has no measurable efficacy except that it creates a placebo effect, meaning that the act of taking this medication (or others) is enough to convince the user the treatment is effective.

Research 

• The Natural Medicines Comprehensive Database rates Valerian as "possibly effective" as a treatment for insomnia. 
• "A randomized clinical trial of valerian fails to improve self-reported, polysomnographic, and actigraphic sleep in older women with insomnia." Taibi DM, Vitiello MV, Barsness S, Elmer GW, Anderson GD, Landis CA . Sleep Medicine 10 (2009) 319–328 [PDF]
• "A randomized, double blind, placebo-controlled, prospective clinical study to demonstrate clinical efficacy of a fixed valerian hops extract combination (Ze 91019) in patients suffering from non-organic sleep disorder." Koetter U, Schrader E, Käufeler R, Brattström A. Phytother Res. 2007 Sep;21(9):847-51. (abstract only)
• "A systematic review of valerian as a sleep aid: safe but not effective." Taibi DM, Landis CA, Petry H, Vitiello MV. Sleep Med Rev. 2007 Jun;11(3):209-30. (abstract only)
• "Critical evaluation of the effect of valerian extract on sleep structure and sleep quality." Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I. Pharmacopsychiatry. 2000 Mar;33(2):47-53. (abstract only)
• "Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability." Wheatley D. J Psychopharmacol. 2005 Jul;19(4):414-21. (abstract only)
• "Valerian for insomnia: a systematic review of randomized clinical trials." Stevinson C, Ernst E. Sleep Med. 2000 Apr 1;1(2):91-99. (abstract only)
• "Valerian overdose: a case report." Willey LB, Mady SP, Cobaugh DJ, Wax PM. Vet Hum Toxicol. 1995 Aug;37(4):364-5. (abstract only)

Dosage

According to research cited at WebMD, dosage to treat inability to sleep is "400-900 mg Valerian extract up to 2 hours before bedtime for as long as 28 days, or Valerian extract 120 mg, with lemon balm extract 80 mg 3 times daily for up to 30 days, or a combination product containing Valerian extract 187 mg plus hops extract 41.9 mg per tablet, 2 tablets at bedtime for 28 days." In all cases, it is recommended that you take Valerian 30 minutes to 2 hours before bedtime.

The University of Maryland Medical Center offers these dosage recommendations: "For insomnia, Valerian may be taken 1 - 2 hours before bedtime, or up to 3 times in the course of the day, with the last dose near bedtime. It may take a few weeks before the effects are felt.

• Tea: Pour 1 cup boiling water over 1 teaspoonful (2 - 3 g) of dried root, steep 5 - 10 minutes.
• Tincture (1:5): 1 - 1 1/2 tsp (4 - 6 mL)
• Fluid extract (1:1): 1/2 - 1 tsp (1 - 2 mL)
• Dry powdered extract (4:1): 250 - 600 mg
• Once sleep improves, keep taking Valerian for 2 - 6 weeks.

Dr. Andrew Weil suggests using "products standardized to 1% valerenic acid."

Side effects

Use of Valerian may cause headache, excitability, uneasiness, insomnia, and next-day "hangover." It may impact performance, so users should not operate machinery or drive while taking Valerian. Pregnant women or women who are breast-feeding should be advised that there isn't enough information about the safety of taking Valerian during these situations to show that it is safe to use. Note that Valerian may depress the central nervous system and should be avoided prior to and during surgery as a safety precaution as it may dangerously impact the body's response to anesthesia.

Risk of addiction

Valerian has not been shown to be overly addictive physiologically, but Dr. Andrew Weil suggests it might become addictive psychologically.

Risk of overdose

Research has not shown evidence of Valerian overdose aside from one case which showed benign results.

Drug interactions

It is recommended that you avoid taking Valerian when drinking alcohol. Other drugs that may interact with Valerian include sedatives in the benzodiazepine and CNS depressant families. It is also important to note that Valerian may decrease the liver's ability to break down other medications, which can lead to unwanted increased effects or side effects from those medications. Dr. Andrew Weil advocates against using Valerian with kava. Other herbs and supplements which might have negative interactions with Valerian include these popular remedies: L-tryptophan, melatonin, St. John's wort, and skullcap (please note that this list is not exhaustive).



Sources consulted

Mayo Clinic/Timothy Morgenthaler, MD || Diseases and Conditions--Insomnia
Medline Plus || Valerian
National Institutes of Health/Office of Dietary Supplements || Valerian
University of Maryland Medical Center || Valerian
WebMD || Valerian
Dr. Andrew Weil || Valerian





A friendly reminder that links to websites offering products does not imply endorsement by SleepyHeadCENTRAL.com.

SleepyHeadCENTRAL strongly encourages people with ongoing sleep health problems to approach a medical professional to determine appropriate differential diagnoses and treatment. This post, like all other posts on SHC, is not intended to substitute for medical advice.  

Alternatives: What about Melatonin, anyway? America's favorite OTC sleep remedy may work... or not...

Melatonin, as a natural supplement for reclaiming sleep, has never been more popular. It is perhaps the leading "alternative" sleep aid out there. Not only is it cheap and easy to source, but there are thousands of evangelists for this exogenous form of a hormone we naturally produce on our own.

Does it work?

Some basics about melatonin, first.

• Natural (endogenous) melatonin is derived from the neurotransmitter, serotonin, in a chemical process which takes place only during the night. Endogenous melatonin is naturally low during the day and high during the evening as it is inhibited by exposure to light due to the ultrasensitivity of the pineal gland to circadian and seasonal rhythms and cues, the strongest of which is light.
  
• Melatonin is key to modulating the circadian clock in the brain because it signals day-night information to a specific pacemaker in the brain called the suprachiasmatic nucleus. However, secretion of endogenous melatonin is also easily altered by environmental factors like exposure to bright light during the evening or the introduction of a late meal or heavy exercise at bedtime. Other circadian rhythms in other parts of the body can be influenced by disruptions in endogenous melatonin secretion as well, including the digestive system, the systems which regulate core body temperature, even blood pressure and reproductive cycles.
  
• Endogenous melatonin also acts as a vasodilator in the skin, increasing blood flow which results in heat loss and lowered body temperature. These physiological processes, in turn, support the sleeping process.
  
• Interestingly, endogenous melatonin is not essential for circadian rhythms; the removal of the pineal gland shows very little impact on these rhythms in humans.
  
• Abnormalities in endogenous melatonin secretion are most commonly associated with the following three psychiatric disorders: Seasonal Affective Disorder (SAD) with winter depression, major depressive disorder, and premenstrual disorder (PMDD). These disorders, in turn, can have a major impact on sleep function, potentially leading to hypersomnia and overeating.
  
• While we secrete our own melatonin in the pineal gland, there is also a manmade form of melatonin (exogenous) which you can also take in pill form. It is rapidly absorbed (within 30 minutes) and has a 40-60 minute half life (meaning it is metabolized and eliminated within this amount of time).
  
• We can purchase exogenous melatonin as an over-the-counter drug because the FDA classifies it as a food supplement and does not require rigorous data supporting its safety, composition or effectiveness.
  
• The exogenous (manmade) form of melatonin is used in two ways: to potentially help shift circadian sleep phases into a more normal pattern, and to serve as a sleep inducer or maintenance drug. Its effect on the suprachriasmatic nucleus is directly related to the amount of endogenous melatonin already being supplied by the pineal gland: those with shortages in endogenous melatonin will feel stronger effects if they take exogenous melatonin. 

• Studies show varying rates of therapeutic success in using exogenous melatonin. The risks of using exogenous melatonin are still unknown; no public health risks have emerged anecdotally. The most common potential side effect is headache. It is considered nonaddicting.
  
• Researchers still cannot agree on an optimal dosage of exogenous melatonin for most people as they have yet to discover a consistent dose-response relationship in studies (the lowest amount which can be shown to be effective).
  
• The effectiveness of exogenous melatonin depends upon the time of day it is administered, though researchers have yet to define an accurate window of time for taking it; the range is as broad as 30 minutes to 3 hours. It has been noted that if people take exogenous melatonin during the day, it may result in impaired function while driving a car, operating machinery or during job performance.
  
• The reason why research is so inconclusive about exogenous melatonin usage resides in the fact that while many studies have been conducted, the variables (dosage, type of subject tested, timing of dosage) vary wildly and cannot be cross compared. 

So, does it work? You be the judge. Here are some articles to consider before jumping on the melatonin bandwagon.

Cleveland Clinic || Melatonin Supplement Review

Mayo Clinic/Dr. Brent Bauer || Is melatonin a helpful sleep aid — and what should I know about melatonin side effects?

Wise Geek || What Are the Pros and Cons of a Melatonin Sleep Aid?

----

Resources consulted

"Biochemical Pharmacology of Sleep." Chokroverty, S. From Sleep Disorders Medicine; Butterworth Heinemann, 1999.

"Circadian Rhythm Sleep Disorders." Berry, RB. From Fundamentals of Sleep Medicine; Elsevier, 2012.

"Clinical Pharmacology of Other Drugs Used as Hypnotics." Buysse, DJ. From Principles and Practices of Sleep Medicine, eds. Kryger, Roth and Dement; Elsevier: 2011.

"Melatonin and the Regulation of Sleep and Circadian Rhythms." Guardiola-Lemaitre, B and Quera-Salva, MA. From Principles and Practices of Sleep Medicine, eds. Kryger, Roth and Dement; Elsevier: 2011.

"Pharmacologic Treatments: Other Medications." Krystal, AD. From Principles and Practices of Sleep Medicine, eds. Kryger, Roth and Dement; Elsevier: 2011.



A friendly reminder that links to websites offering products does not imply endorsement by SleepyHeadCENTRAL.com.

SleepyHeadCENTRAL strongly encourages people with ongoing sleep health problems to approach a medical professional to determine appropriate differential diagnoses and treatment. This post, like all other posts on SHC, is not intended to substitute for medical advice.  

ABCs of Sleep---C is for CPAP

A typical CPAP machine is small
enough to put on your nightstand
and includes a humidifier and
other simple adjustments.

CPAP

Continuous Positive Airway Pressure. A device for treating obstructive sleep apnea and other sleep-related breathing disorders.

____________________

CPAP is a common therapy which involves wearing a mask hooked to a machine delivering continuous air pressure in order to "splint open" the upper airway to prevent sleep obstruction. CPAP therapy is considered the gold standard for treating apneas.

This nasal mask is light enough to be
comfortable while still being an  effective
aid for improved breathing while asleep.

CPAP machines don't actually deliver oxygen to the patient airway via the mask, they just provide the right amount of pressure through the mask to keep the patient's airway "patent" or open. This kind of therapy helps keep the patient fully oxygenated while asleep, preventing a wide array of homeostatic problems such as hypoventilation, oxidative stress on the heart and hypertension. In fact, CPAP is considered a life-saving, life-altering device. Many patients have added years to their lives after using this therapy. Most patients, once adapted and compliant to CPAP therapy, report increased energy during the day and more restful sleep at night.

There are multiple versions of PAP therapies, including Bi-Pap and AutoPap, which regulate pressures through algorithms and preset programs to make the experience of breathing simpler and more comfortable for those with additional or multiple respiratory issues.

Today's CPAP therapy uses various kinds of masks to deliver the pressure, include oral nasal masks with or without chin straps, nasal pillows and full face masks. The technology has rapidly improved in recent years so that machines are far more quiet and deliver more comfortable pressure using built-in humidifiers; the masks today are also made of ultralight hospital grade silicone which is more light and flexible than previous masks.


Links to learn more:

What is CPAP? || National Heart, Lung and Blood Institute
How CPAP controls sleep apnea || Mayo Clinic (VIDEO)
Sleep and CPAP Adherence || National Sleep Foundation
AASM Recommendations for Treatment || SleepWell Solutions

____________________

*SOURCE for DEFINITIONS:
Spriggs, WH. (2010.) Glossary. In Essentials of Polysomnography (pp585-606). Sudbury, MA: Jones and Bartlett Publishers