Online Health Chat with Carlos L. Rodriguez, MD

December 5, 2016

Description

At Cleveland Clinic’s Sleep Disorders Center, we offer multidisciplinary care for a wide range of sleep disorders in adults and children. We treat each patient's case in a personalized, individual way. Our goal is to achieve the best possible management of all sleep disorder cases.

Sleep disorders are on the rise. It is estimated that nearly 75 percent of adult Americans experience sleep disorder symptoms at least a few nights per week. As many as 25 percent to 30 percent of infants and children also experience some form of sleep disturbances. Sleep loss has a detrimental effect on your overall quality of life, leading to mental and physical health issues that compromise school and work performance, interpersonal relationships and safety.
 
Sleepiness interferes with cognitive function, which can cause learning disabilities in children, memory impairment in people of all ages, personality changes and depression. People suffering from sleep deprivation experience difficulty making decisions, irritability, problems with performance and slower reaction times, which place them at risk for automobile and work-related accidents. Sleep loss can also adversely affect health by contributing to the development of obesity, diabetes and heart disease.

You don’t need to suffer with poor quality sleep or daytime sleepiness. Cleveland Clinic’s Sleep Disorder Center brings together sleep experts from different disciplines including internal medicine, neurology, psychology, psychiatry, pulmonary medicine, otolaryngology, pediatrics and family medicine all under one roof. Together, they offer comprehensive sleep testing options for sleep disorders, including convenient Home Sleep Testing for sleep apnea, and provide a wide-range of therapies to effectively treat sleep disorders.
 


About the Speaker

Carlos L. Rodriguez, MD, is board-certified in neurology, clinical neurophysiology and sleep medicine. He served as a general neurologist in the United States Army for seven years at Brooke Army Medical Center (BAMC), while assuming the role of assistant chief of neurology and chief of neurophysiology at BAMC. Dr. Rodriguez received his training in neurology at Madigan Army Medical Center. He also served as the program director of the sleep medicine fellowship at the Cleveland Clinic. His specialty interests include parasomnias, sleep-related breathing disorders, restless leg syndrome, insomnia, central hypersomnias, circadian rhythm disorders, hemifacial spasm and general neurology.


Let’s Chat About Sleep Disorders

Early Morning Musings

GeorgeB: I am a 66-year-old male, and I exercise vigorously (running, strength training, etc.) most days. I have been waking up after about three hours sleep, stay wide awake, and am unable to fall back asleep. Then, I spend the next day very lethargic and taking multiple naps. This happens particularly after heavy exercise or if I am stressed.
Taking 25 mg to 50 mg of generic Benadryl seems to alleviate the problem, and if I do wake up, I can fall back to sleep and usually get six to eight hours of sleep and feel energetic and rested the next day. Is this the best way to handle this problem?

Carlos_L._Rodriguez,_MD: Your solution is effective, but tolerance to Benadryl can ensue with long-term use. A better solution would be to determine why you are waking up and then prevent this night-time awakening. There are a multitude of potential causes of early morning awakening that are readily correctable. Of note, exercise is good for sleep as long as it is not performed within a few hours of sleep onset. Otherwise, this exercise can cause sleep initiation difficulty, which does not appear to be an issue for you. Daytime napping can perpetuate insomnia because when you nap during the day, you are taking away from your sleep at night. We recommend avoidance of daytime napping to help facilitate sleep at night. Consider being evaluated by a sleep specialist to determine why you wake up and to identify the best solution for the source of the insomnia. 

faithwalk: I am 68 years old, and lately have been waking at 3 a.m. or 4 a.m. with no chance of going back to sleep. Why? I am aware that other people in my age group also wake early, even though they did not during their younger years.

Carlos_L._Rodriguez,_MD: There are a multitude of reasons why patients awaken in the early morning hours. These causes range from depression to sleep apnea. While it is true that as we age our circadian rhythms weaken and we are prone to more awakenings from sleep and more prone to take naps during the day, this should not simply be accepted. Many patients needlessly suffer when treatment is available. Consider seeing a sleep specialist.  

outlyarr: Hello. I am a 63-year-old male. My sleep pattern is odd. I go to bed, seemingly lucid, about 8:30 p.m. to watch a little TV, and I usually "pass out," only to awaken at 12 p.m. or so and toss and turn until 3 a.m. or 4 a.m. Then, I fall back to sleep until 6 a.m. I hate this "big hole" in my sleep. I have tried Sonata and diazepam 10 mg with no results. May I have your input or suggestions?

Carlos_L._Rodriguez,_MD: In order to help you, we have to determine why you wake up at midnight. There are a variety of potential sources. Some common causes include sleep apnea, insomnia (including all of its derivations), and psychiatric and medical sources of sleep fragmentation. In an evaluation, we ask a host of questions to determine what is waking you up. Once we have identified the source, then proper treatment can commence. Medications can be used to treat insomnia, but they only cover the insomnia rather than cure the underlying source. As such, these medications will have to be used indefinitely if the insomnia is a long-term issue (more than several weeks). The use of these medications long term can result in addiction (with some) and tolerance (with most/all). Tolerance is the phenomena of needing to take increasingly large doses to achieve the same effect, and thus is not a good long-term solution because side effects ensue. There are non-medication solutions for insomnia that correct the underlying source. Consider seeing a sleep specialist to address your sleep disorder.   


Sleep Apnea Notes

chatter23: I am a 57-year-old woman who was diagnosed two years ago with REM-specific apnea after years of fatigue. I have used my CPAP every night and am still exhausted with fibromyalgia symptoms. This would seem to suggest I am still not getting restorative sleep. I take a small amount of Trazodone for sleep. I took iron supplements for a year for restless legs, and that helped that symptom by getting my ferritin above 50. My thyroid tests are normal, as is all other blood work. Is there anything you would suggest in terms of testing or treatment? Thank you. PS. In addition to my question, I wanted to add that I do not take naps. Naps generally don't help me feel rested. Thanks.

Carlos_L._Rodriguez,_MD: The first step is to ensure that your REM-specific sleep apnea is well-controlled. This is commonly accomplished by reviewing a CPAP download, which will determine how compliant you are with treatment, whether there are significant mask leaks and whether the sleep apnea is well-controlled. If all of these findings are good, then this would suggest that the OSA is well-controlled and your non-restorative sleep is a result of some other disorder. The next step would be to ensure that the restless legs syndrome (RLS) is well-controlled. This is determined by your subjective report of whether you have an ongoing urge to move the legs. Approximately 85 percent of people with RLS have periodic limb movements during sleep, which can also cause non-restorative sleep. What would be helpful is a history and physical examination by a sleep specialist to determine the above and whether other sleep disorders are present that are causing the non-refreshing sleep. 

chatter23: Thanks. Yes, my apnea is very well-controlled, there are no leaks, and my AHI is typically around 0-1. Also, I believe my RLS is much better since taking iron, and most evenings it does not bother me. I have been disappointed to still not feel like I'm getting restorative sleep.

lal: My wife often lightly snores at night, and I do hear her choke or cough during sleep once every few days if I am awake during the night. She takes a small amount of Ambien and melatonin to get good sleep almost every night, often getting up in the morning to take a little more. She has good energy when she sleeps longer but less when she doesn’t. What do you suggest for her?

Carlos_L._Rodriguez,_MD: Your wife needs a sleep study to determine if she has sleep apnea. It is unusual for a bed partner to misinterpret seeing someone stop breathing during their sleep. Untreated sleep apnea can cause high blood pressure and has been associated with a variety of concerning disorders include heart attack, stroke, irregular heart beat and heart failure. 


CPAP Specifically

Mike: Thank you for the opportunity. I presently am using a full-face mask, and my doctor set the air pressure at 19. Can you explain how the air is forced into the nose/mouth during the time I am sleeping? It seems that I also have AHI events even when I have a good seal, usage hours, mask off/on report. Is this a common occurrence? Why would the machine seem to ramp up around 4 a.m. to 5 a.m.? What causes the ramp up to occur? I find that when the air is being delivered at its peak pressure, it becomes difficult to keep a good seal on the mask. Thank you.

Carlos_L._Rodriguez,_MD: You are on a very high CPAP setting. The air is forced through the hose into the mask and then through your nose and mouth to the back of the throat where the obstruction typically takes place. This pressure holds the airway open and thus prevents obstructive respiratory events. It is believed that having some respiratory events is perfectly normal as long as the AHI is less than 5. Some patients can have an AHI of >5 that may be the result of an inappropriate CPAP setting (too high or low), significant mask leaks or the development of central respiratory events. If you have a fixed CPAP machine set at 19 cmH20, and it was not turned off or a ramp used, it should not increase in pressure. An auto-CPAP machine is always adjusting to your pressure needs, and this machine could certainly explain why the pressure is ramping up at 3 a.m. to 4 a.m. By the way, if you go to bed at 9:00 p.m. to midnight, then by 3 a.m. to 4 a.m., you may be in REM sleep, which often requires higher CPAP settings. There are several solutions for mask leaks:1) wash the mask daily; 2) wash your face nightly; 3) consider using a cloth mask insert (one brand name is REMzzz; 4) if all above fail, then consider a different mask.

berm: I had a polysomnogram that revealed seven apnea episodes per hour, so I have been using a CPAP machine for a year now. However, my sleep pattern has not changed with the CPAP. I am tired and sleepy during the day (which was the reason for sleep study) as I was before using CPAP. I am 89, have a history of: 1) CABG in 1982 and nine angioplasties since then; 2) my HTN is controlled with Coreg and clonidine; 3) I have had Afib since 2001 and am taking Coumadin, but I had to stop amiodorone due to side effects. Question 1: Should I continue with the CPAP: Question 2:  Could you suggest other tests or treatments? Thank you.

Carlos_L._Rodriguez,_MD: CPAP is an important treatment for OSA in patients who have atrial fibrillation. Studies have demonstrated that the use of CPAP does reduce the recurrence of atrial fibrillation and can reduce incidence of heart attack. The first step is determining whether the OSA is well-controlled using your current setting of CPAP. This can be accomplished by obtaining a download to determine how many hours you are using the device, whether there is an excessive leak and whether the OSA is well-controlled (AHI<5). If all of these things are good, then a history and physical exam needs to be performed to determine whether other sleep disorders are present that could account for your residual excessive daytime sleepiness. 


Medication Meditation

Barney07: I have had sleep issues for years, along with several autoimmune diseases. I currently take gabapentin for sleep, which is prescribed by my rheumatologist, but I try not to take it all the time due to concerns about long-time use. Do you have any suggestions for natural options, or what is your opinion of this medication. I can take up to 600 mg per night, but I try not to take more than 500 mg. (I always ask for 100 mg tablets to take the least amount needed.) After two to three days of not getting enough sleep, I end up taking 500 to 600 mg. Thank you.

Carlos_L._Rodriguez,_MD: Gabapentin is a medication that was developed for control of seizures. It is a very safe medication that has been used since the 1990s.There are no long-term repercussions from its use that we are aware of thus far. This medication is able to both control pain and enhance sleep, which has synergistic effects. I am not aware of a natural substitute that could accomplish both of these objectives. It is important for you to consider seeing a sleep disorder provider to determine if you have an actual sleep disorder that is responsible for your sleep issues and would require independent treatment.


Young Sufferers

sharonk: My teenage daughter (16) has struggled with sleep for some time. I believe it's because she is constantly thinking, possibly worrying (type A personality). What signs do I need to look for that would tell me that she may be struggling with a sleep disorder and may need to see a doctor?
 
Carlos_L._Rodriguez,_MD: Signs/symptoms to watch for include non-refreshing sleep, difficulty awakening in the morning, mood changes, worsening grades, excessive daytime sleepiness, daytime fatigue, presence of over-the-counter sleep aids (use of Nyquil, Tylenol PM, etc.) or stimulants (for example, 5 Hour Energy, energy drinks, etc.). A pediatric sleep physician could be helpful in correcting your daughter's sleep issues.

kldev: My 10-year-old has anxiety and sleep issues. We have not found a medication that helps with the anxiety. We give him 3 mg of melatonin about five nights per week. Do you see any problems with this?

Carlos_L._Rodriguez,_MD: Please consider seeing a pediatric sleep specialist. These physicians routinely see patients just like your son to help ensure he sleeps well at night.


Unique Technique

liesel: I am a 77-year-old female. I exercise daily and live and eat very healthy. I do have heart disease, basically blockages in LAD (five stents). I have been suffering from chronic insomnia for many years. I believe it is hormone related, at least it used to be.
I do all the suggested things: go to bed at the same time, cool bedroom, no electronics ½ hour before bed, etc. I also have been tested for sleep apnea. I have also tried various relaxation tapes, yoga, etc. Over the years, I have tried almost all over-the-counter medications, including melatonin, valerian, teas, etc. I also have tried quite a few prescription sleep aids. Lunesta worked for a while until it went generic, which does not seem to help. I have difficulty falling asleep and staying asleep. Last night again, I could not fall asleep, and this morning I woke up at 3:30. I do believe that my insomnia contributes to my heart disease. Do you have any suggestions for me?

Carlos_L._Rodriguez,_MD: An excellent long-term solution for this problem is cognitive and behavioral therapy for insomnia (CBT-I), which entails much more than sleep hygiene and relaxation tapes. This can be performed online, via group meetings and one-on-one. One-on-one CBT-I is performed by attending meetings once per month (most commonly for four months), and each visit you are taught a different CBT-I technique. This is very helpful for about 70 percent of patients, but it is not a passive process. Patients are taught techniques that require much practice, buy in and motivation on the patient's part. I think this is your best hope.   

curefansc: My son is 21 and refuses to take sleep medications (even over-the-counter ones) because he is afraid of becoming addicted to them, so he has been suffering from insomnia symptoms for a couple of years now. He has tried natural remedies such as music and app downloads, but nothing seems to be helping. Do you have any suggestions?
 
Carlos_L._Rodriguez,_MD: Provided your son has insomnia, a sleep psychologist could readily treat your son's condition using non-medication approaches that are referred to as CBT-I. Please see other response.


Sleeping Conditions

sbd: Sleep inertia ruins my mornings. Is there any way to stop or lessen it?

Carlos_L._Rodriguez,_MD: Sleep inertia is manifested by having great difficulty awakening in the morning and the need for multiple alarm clocks. In addition, family members often have to call to help awaken the patient, and once the person is awakened, they are groggy, confused, prone to mistakes, automobile accidents etc. Treatment of this symptom depends on the cause. Sources of this symptom include: Central hypersomnias (like narcolepsy and idiopathic hypersomnia) and the use of long-acting stimulants at night or early morning short-acting stimulants. Other, less common causes are delayed sleep phase syn, which requires the use of phototherapy and melatonin, and OSA, which can be treated a multitude of ways, but the first line approach is CPAP. 

pest02basil: I sleep very little. Even as a baby, I slept only about four to five hour per day. It drove my mother crazy, and it’s stayed the same all my life. I'm 68 years old and maybe get four hours of sleep at night. I've been to several doctors, neurologists etc. over the years, with no diagnosis. One doctor felt that it is from a genetic disorder. Do you have any thoughts? Thank you.

Carlos_L._Rodriguez,_MD: One possible cause is idiopathic insomnia, which is characterized by an early onset, the absence of an inciting source (i.e. abuse, etc.) and an unrelenting course. This is a difficult-to-treat insomnia. I would recommend an evaluation by a sleep disorders specialist to determine if this is really the source and to rule many other more treatable conditions. This is not to say that there is no hope for patients with idiopathic insomnia. Treatment with CBT-I and medication may be helpful. 


Closing

That is all the time we have for questions today. Thank you, Dr. Rodriguez, for taking time to educate us about Sleep Disorders.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.


For Appointments
To make an appointment with Dr. Rodriguez or any of the other Cleveland Clinic specialists please call 866.320.4573 or learn more on our website at clevelandclinic.org.

For More Information

Cleveland Clinic

Cleveland Clinic's Sleep Disorders Center is a multispecialty, comprehensive program dedicated to the diagnosis and treatment of sleep disorders in children and adults. Accredited by the American Academy of Sleep Medicine, the center is comprised of specialists in neurology, pediatrics, pulmonary medicine, psychiatry, psychology, otolaryngology and family medicine.

Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments for sleep disorders.

Sleep Basics
http://my.clevelandclinic.org/services/neurological_institute/sleep-disorders-center/patient-education/hic-sleep-basics

Sleep Glossary
http://my.clevelandclinic.org/services/neurological_institute/sleep-disorders-center/patient-education/hic-sleep-glossary

Common Sleep Disorders
http://my.clevelandclinic.org/health/diseases_conditions/hic_Common_Sleep_Disorders

Sleep Apnea
http://my.clevelandclinic.org/services/neurological_institute/sleep-disorders-center/disorders-conditions/hic-sleep-apnea

Sleep & Aging
http://my.clevelandclinic.org/services/neurological_institute/sleep-disorders-center/patient-education/hic-sleep-and-aging 

Sleep Studies
http://my.clevelandclinic.org/health/diseases_conditions/hic_Sleep_Studies

Cleveland Clinic Treatment Guide
http://www.clevelandclinic.org/lp/sleep_disorders/

Clinical Trials
http://my.clevelandclinic.org/services/neurological_institute/sleep-disorders-center/research-clinical-trials

For additional information about clinical trials, visit: https://clinicaltrials.gov/.


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