Recent Research: In the News

Pharmacotherapy Failure in Chronic Insomnia Patients



Published in the Mayo Clinic Proceedings
Pharmacotherapeutic Failure in a Large Cohort of Patients With Insomnia Presenting to a Sleep Medicine Center and Laboratory: Subjective Pretest Predictions and Objective Diagnoses

Articles

Assess Your Sleep

Sleep Quality Index

Posted in Assess Your Sleep

For the vast majority of troubled sleepers, the Sleep Quality Index is the single most important way to analyze your sleep problems.  While no written survey is comparable to actually testing your sleep quality in a sleep lab, these brief questions pinpoint  the most common symptoms in those people suffering from sleep quality problems.  Test yourself now and in seconds you'll receive revealing feedback



Understanding your score

The questions on this survey speak to many different areas of sleep quality.  The more questions you mark in the medium to high range, the more severe the sleep quality problem.

Some questions reveal things about your sleep based on simple facts about sleep behavior.  If you cannot sleep well on your back or cannot sleep well in a warm or stuffy room, you would be describing two problems commonly reported by people with sleep breathing problems.

If your sleep is restless, you can't get comfortable, you move a lot, or you feel worse after a nap, then you are not describing yourself as a normal sleeper. You might be suffering from general sleep quality problems or something specific like a leg movement disorder .

If you think of your sleep as broken, too light, and you can't sleep through the night, then your sleep quality problems again are probably severe and strongly suggest the presence of insomnia.  In the worst case, you may have grown dependent on sleep aids or prescription sleeping pills , which usually turns out to be a very poor choice for insomnia treatment.

All these examples highlight sleep quality as the critical factor that underlies most sleep problems.  Whether it be sleep breathing or sleep movement problems or whether it's insomnia or other interruptions in your sleep, sleep quality is most often the underlying cause.  When you learn to think in the dimension of sleep quality, you will find solutions to your sleep problems much faster.   

 

Why Pills Can't Improve Quality

It's important to understand that your body is designed to sleep well and all through the night.  The notion that a pill could fix a sleep problem such as insomnia is not illogical; it's simply irrational if the real cause is an underlying sleep quality problem.  If you could fix your sleep quality problem and eliminate your insomnia, it would be very clear you don't need pills. 

In our view, most insomniacs do not benefit from sleep medications except in the very short-term.  Indeed, to quote the Food & Drug Administration's mandated warning that was sent out to healthcare professionals by the pharmaceutical manufacturers of prescription sleeping pills:

"The failure of insomnia to remit after 7 to 10 days of treatment [i.e., drug treatment] may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated."

In our experience the single most common missing element is a sleep quality problem, which requires much more evaluation and usually overnight testing in a sleep lab.  In all your efforts to resolve your sleep problems, we believe sleep quality is "where it's at" more than 80% of the time.

 

Chronic Insomnia Assay

Posted in Assess Your Sleep


Chronic Insomnia Assay (CIA)

There are several definitions of insomnia, but the most widely used refer to difficulties you may have falling asleep or staying asleep.  Some sleep researchers and physicians refer to poor sleep quality as insomnia.  While that perspective may be valid, we prefer to keep the two terms separate.   Complete the Chronic Insomnia Assessment below and then read a quick analysis of your results.



Understand your score

Insomnia comprises many elements, the most important of which are unwanted or unplanned periods of sleeplessness, distress over this sleeplessness, and interference with your waking life.  Other signs of insomnia include the need for medication to assist you in sleeping; a perception that nothing is wrong with your sleep, you just want or need more of it; and, some concerns that the problem has no obvious solution. 


If you scored in the medium to high range for virtually any of these questions, chances are very high you suffer from a chronic insomnia problem.

 

Sound Sleep, Sound Mind is the perfect next step for you, because it sheds more than a night light on the potential cure for your insomnia. A cure really is possible for a lot more insomniacs than most imagine, because our method provides tools and techniques like no other book or program on the market.  Our program known as Sleep Dynamic Therapy is full of information to help you realize that most insomnia is a mind-body problem, and when you attack all the mental and physical elements of insomnia, you will often learn to sleep, drug-free, all through the night.

Sleep Misery Index

Posted in Assess Your Sleep

The Sleep Misery Index is an invaluable tool to rapidly analyze the impact of your sleep on your health and well-being.  Instead of puzzling over your actual sleep, this tool teaches you how to assess what your sleep is "doing" to you, which is an excellent indirect means of measuring your own sleep quality.

Sleep Breathing Survey

Posted in Assess Your Sleep

Sleep breathing problems are the single most common physical disturbance in someone who suffers from poor sleep quality.  Whether you suffer from insomnia, complain of nightmares, restless or jerking legs, or show signs of poor functioning on the Sleep Misery Index, remarkably, breathing problems are the most universal finding among all these types of troubled sleepers. 

Many with sleep problems have a great deal of difficulty accepting or appreciating the role of breathing when it comes to sleep.  But, let's stop for a moment and ask ourselves, "what is the single most important physiological function of the human body?"  Answer:  Breathing!  Indeed, if you stop breathing for just a few minutes, the risk of brain damage is enormous.  Think about the role of CPR; why is it so important to pump on the chest wall?  Answer:  To deliver oxygen to the brain and to the muscles of the heart.

If breathing is so important to your survival, I would ask, "how could breathing not be an important factor in your sleep? How could it not have a major influence on your slumber?" 

As you will soon discover, breathing is critical to Sound Sleep, because even the slightest disruptions in breathing can lead to major disruptions in your sleep. Yet you must  this crucial point: it is extremely difficult, if not impossible, to gain any awareness about your own sleep breathing disruptions, because you are asleep when they occur.

If you want to figure out now whether or not breathing could play an important role in your particular sleep disturbance, I invite you take the 3 survey components below.  Each component shows you a different way to predict whether or not you suffer from a relevant sleep breathing condition.  

PAP Therapy Checklist

Posted in Assess Your Sleep

Very few people will tell you that their CPAP worked perfectly out of the box. It requires patience to get right. But if you take heart, and maintain persistence, the results can be amazing. To get that match, you'll be trying masks and pressures, and perhaps various PAP technologies. The following survey shows you questions that help us determine how patients are doing in their quest for the optimal result, and indicate how we might be able to improve things.

PAP Therapy Follow-up Form

The Mask

{slide=Does the mask cause you any pain?|closed}

  • No mask should cause pain; if the pain cannot be eliminated; it’s the wrong mask
  • Repositioning, loosening straps and insuring that the mask is the right size and properly applied to the face may solve the problem
  • Pain may be due to the wrong style; consider whether your facial features would do better with a full face mask, an over the nose mask, or a nasal pillows interface, or one of the new combo interfaces.
  • No mask should cause discomfort; if the discomfort cannot be eliminated; it’s the wrong mask
  • Repositioning, loosening straps and insuring that the mask is the right size and properly applied to the face may solve the problem
  • Discomfort may be due to the wrong style; consider whether your facial features would do better with a full face mask, an over the nose mask, or a nasal pillows interface, or one of the new combo interfaces.
  • Comfort issues can often be remedied with “jury-rigging,” for example, bandaides, gauze, paper tape, Velcro straps, etc. may be attached and manipulated in various ways on the mask to further displace pressure to relieve discomfort

{slide=Does the mask leak?}

  • Regular cleaning of mask, usually once a week with mild soap and warm water; Daily if facial oil residues are present
  • Avoid applying facial creams/lotions to area of face where mask makes contact.
  • Leaking is most often due to the wrong size mask, poor fitting mask, mask not snug enough, or improperly applied mask to facial surface.
  • Old masks are another common cause leaks as the material may crack or simply not hold its position in a stable manner against the face.

{slide=Are you satisfied with your overall fit?}

  • Verify proper headgear fit and proper adjustment
  • Verify proper mask size
  • Switch to another mask, perhaps different style; and/or switch between styles every couple of days
  • Improvise as needed to improve the fit of the mask, using “jury-rigging.”  You’ll find many tips on www.cpaptalk.com.

{/slides}

The Pressure

{slide=Does pressurized air cause you any discomfort?|closed }

  • Pressure may be too high
  • Pressure may be just right, but you haven’t adjusted to pressure yet.  Talk with your doctor about using a ramp function or starting out with lower pressures.

{slide=Does pressurized air cause you any difficulty breathing? }

  • Pressure may be too high
  • Pressure may be just right, but you haven’t adjusted to pressure yet.  Talk with your doctor about using a ramp function or starting out with lower pressures.

{slide=Does pressurized air make it hard to breath against the pressure?}

  • This is a very common complaint, and suggests that the individual is having trouble breathing out when pressurized air is coming in.  In general we find this occurring in more sensitive or anxious patients, yet it can occur in almost anyone on fixed CPAP pressures.  For this reason, we now use a device called bilevel that drops the pressure during exhalation and
  • In particular the CPAP Pressure may be just right on inhalation but too high for exhalation.
  • Pressure may be just right, but you haven’t adjusted to pressure yet.  Talk with your doctor about using a ramp function, starting out with lower pressures, or coming back for a bilevel retitration study.

{slide=Are you adjusting well to pressurized air? }

  • If mask and pressures issues have been attended to and the adjustment is still not going well, then it is imperative to meet with your sleep medical provider to discuss the problem
  • You may be have the wrong pressures or the wrong pressure delivery system and only by going back to the sleep lab for another titration test can these issues be addressed
  • If big factor here could be mouth breathing or related problems with breathing through your nose.  If you continue to mouth breath or notice difficulty in breathing through your nose, then an evaluation by an ENT specialist or an allergist is well worth you time.
  • Too much humidity can also be a factor in difficulty breathing with PAP.  Make sure your humidifier heat setting is set just to where you don’t have dry mouth but make sure also that there is no condensation in your mask.

{/slides}

The Side Effects

{slide=Have you developed any sores or skin irritations?|closed}

  • Issues regarding mask pain/discomfort may be the major irritants
  • Diabetics, elderly or those with otherwise sensitive skin may need to develop a routine of alternating two different types of mask to relieve pressure on the affected skin surface and allow time for healing.
  • Simple’ intra-nasal irritations, due to mask and/or air pressure contact point, can sometimes be alleviated with special creams like…

{slide=Have you developed any air swallowing or feeling bloated in the morning?}

  • There can be several causes of this symptom, the most common of which is mouth breathing, which may be remedied by wearing a chinstrap, mouth taping, or a full face mask.
  • It’s also very important to consult with your sleep physician, because, we have found that many people with air swallowing (aerophagia) suffer from another sleep disorder known as leg jerks [(periodic limb movement disorder (PLMD)].  It seems that the leg jerks awakens the patient who then swallows air.  We’ve noted that many patients treated for leg jerks no longer report aerophagia.

{slide=Have you developed any worsening of allergies, congestion, or sinus problems? }

  • Proper maintenance and regular cleaning of machine, machine filters, tubing, humidifier chamber and mask are needed to keep bacteria and other irritants to a minimum.
  • A very large number of CPAP users must develop an aggressive program to treat allergies or congestion by using regular nasal saline rinses of the nasal passages or Netipot washes, anti-allergy sprays such as Nasalcrom, Nasal Steroids and related medications such as antihistamines, and regular use of a nasal dilator strips such as Breathe Right.  Developing a zero tolerance policy towards nasal congestion is a major step forward in optimizing the response to PAP therapy.
  • Some people with a condition known as “non-allergic rhinitis” notice that the air blowing into their nasal passages worsens their congestion. These individuals must develop a precise program with their primary physician or allergist to solve the problem, otherwise pressurized air will continue to aggravate the congestion.

{slide=Have you developed any claustrophobia?}

  • Claustrophobia usually arises in two types of patients.  The first is the patient with true claustrophobia for which additional treatment such as a specific phobia desensitization may be needed before the patient attempts regular use of the breathing mask.
  • The second and more common type is a quasi-claustrophobia response in which the patient suffers some anxiety that might trigger panicky feelings. With the proper mask and pressure desensitization steps, these feelings usually subside.
  • Many patients with difficulty breathing through their noses are more at risk for claustrophobic responses.  We see patients with deviated septums respond much better once the nasal passages were evened out.  So, a visit to your ENT Physician may be important.

{slide=Have you developed any embarrassment?}

  • Although this symptom is declining because so many people are now using and embracing PAP therapy, there are still a fair number of CPAP users whose major barrier is embarrassment.
  • Embarrassment usually develops for a few difference reasons, the most common being that it feels uncomfortable to be wearing such a weird device around a loved one, and the device would not appear to invite or encourage romantic encounters.
  • Regrettably, we haven’t figured out a way to convert all the tubes and straps into some kind of dual purpose sex toy, but we hope you can appreciate that if PAP therapy works well for you, it has the tendency to increase energy levels in general and libido specifically.
  • Embarrassment issues may be so strong in some users, it actually becomes a therapy issue requiring marital or couples counseling
  • Embarrassment is an emotion that if left unchecked can intensity into stronger emotions such as shame.  The most important first step for anyone who suffers from embarrassment about using PAP therapy is be honest with yourself about the feelings, and then if feasible talk to the person with whom this feeling arises in the bedroom

{/slides}