Seeking veteran to review my sleep "scheme" and tell me what I might be missing

[NightOwl42]

Hello,

I recently had a comprehensive, in-lab sleep study* which concluded that I am getting "proper sleep", and that my CPAP is effectively controlling my OSA. To follow-up, I met with the sleep medicine doctor, and she clarified that I have nothing but sleep apnea--no circadian rhythm disorder, restless legs, or anything else. I am getting sufficient R.E.M. sleep. 

This was reassuring, but I'm still having sleep and fatigue issues. Here's the breakdown:

• Take 200-300 MG Gabapentin for its off-label side effect of inducing drowsiness.
  
• I use my CPAP, a Resmed S9 Auto, pressure 6-12 with humidifier. Nasal pillow mask, micropore mouth tape. I don't like using a CPAP, but at this point, I tolerate it well. I have adjusted my CPAP settings several times, and I feel like I have them dialed in. I believe it is about as comfortable and effective as it's going to get.
  
• In bed between 10:30 and 11:30 PM, listen to podcasts for 20-60 mins until I start drifting, then I turn it off, attach mask, and sleep.
  
• Wake up 1 or 2 times to pee. Sometimes it takes me a while to return to sleep.
  
• Then I generally wake between 5-7 AM feeling like I need more sleep. I remove the mask and sleep for 1-2 more hours, eventually waking but feeling incredibly groggy, like I still need more hours of sleep in order to face the day.
  
• I generally don't nap, but am tired enough that I can easily take one in the afternoon.
  

Other stuff:

• I exercise daily, running, walking, Pilates. It's not as intense as I would like during winter, but I keep up the habit.
  
• Not overweight.
  
• I practice good sleep hygiene, killing all screens 60-90 minutes before going to bed.
  

I recognize there are psychological components to sleep problems, beyond the scope of this forum to address. However, I'm wondering if anyone would review the above and tell me if I'm missing anything.

Thanks in advance,
Night Owl

* Full overnight with every possible electrode hooked up. The next day, a "nap challenge" where I was supposed to try to nap at intervals throughout the day. I believe this was to check for narcolepsy.

[SarcasticDave94]

What did your detailed sleep study state? Did you get your copy? Post a redacted copy here. And what does the daily detail tab on OSCAR show?

I think as of now, the only thing you might be missing in the text is EPR if you have that option.

I take melatonin about an hour before bed most nights. Since my health insurance has an OTC allowance, they paid for it. I used to be on a "side effect" sleep pill as well.

[Ratchick]

Why do you take the mask off then go back to sleep? That's not going to help with the drowsy. And also, what's the purpose of using Gabapentin for sleeping? I had horrific drowsiness when I was on it for pain therapy and I was literally falling asleep face first in my dinner or standing up at one stage. Those two things alone would catch my eye as causing daytime drowsiness. Beyond that, we'd need to see the charts.

[Sleeprider]

I agree with Ratchick that if you have a OSA problem that requires treatment, you may be undoing the benefits of your therapy by going back to sleep without the benefits of CPAP. We can look at your OSCAR data and see just what things look like, but I suspect much of the problem is untreated sleep on a routine basis. The other thought is that Gabapentin is a strong anti-seizure drug, and although it may aid in drowsiness, it can seriously affect existing breathing problems including apnea. Again, we can look at the data, but I would encourage you to try less aggressive alternatives. The sleep aid with fewest effects is melatonin, but if you need a prescription drug, work with your doctor to find an alternative and see if that helps, and to develop a withdrawal plan for Gabapentin.

[NightOwl42]

@All:

Below are my OSCAR data and sleep study. Using Dropbox due to file limitations w/forum software. 

I appreciate your help.

Regarding the gabapentin, 200 mg is a very low-dose, and I don't believe this medication is known for causing breathing problems. But it is certainly possible.

https://www.dropbox.com/sh/66kfzmn77vpz1...xcpIa?dl=0

[SideSleeper]

Please do some serious research on Gabapentin. Some people can take it without problems, but it can cause some serious problems with others (myself included) and I was taking low dose for nerve (sciatica) problems.

[Dormeo]

One observation about your bedtime routine. Try eliminating the podcast. Standard sleep "hygiene" recommendations include the admonition to use the bed for nothing but sleep and sex. When we are in bed and awake -- even if pleasantly diverted by podcasts or books -- we tend to associate being in bed with being awake.

If you aren't able to go to sleep within 20 minutes of going to bed, get up, go somewhere outside your bedroom, and do something quiet and relaxing until you feel sleepy. This, too, is standard advice.

About the breaks to pee: restrict liquids within 3 hours of bed, especially avoiding diuretics like alcohol and coffee. If you also pee frequently during the day, talk with your doctor about the possibility that you have an enlarged prostate.

For what it's worth, I tried gabapentin (prescribed by my doctor) for a short while but stopped because it left me feeling clobbered the next day -- mentally out of it and in the mood to doze.

[sheepless]

for a bit of counterpoint, I took gabapentin for restless legs/periodic limb movement for a while. can't remember the dose (600mg?). I quit because I didn't notice any effect with respect to rls/plm or sleep (neither better nor worse).

however, in running through the litany of sleep aids with my doctor a few times, all of the ones he described he said tended to leave people feeling drowsy the next day. combined with the fact that many should be used only occasionally, I failed to understand the point of trying to get more rest using medications that were likely to leave me feeling 'hungover' the next day. that's precisely what I want to avoid.

idk your age but I'm starting to understand there may be a reason why people say older people don't get (need?) as much sleep as when we're younger. my new fitness tracker tells me men my age (66) are typically awake 15-31% of the night (waking 10 - 30 times, some of which we're unaware). after a lifetime of untreated apnea, I thought I'd feel so much more rested with pap. I do feel better, but nowhere near as rested as I'd like. 5 years of pap now, I still wake up dozens of times a night, masking off at least 3 times on my best nights, and yet my awake time is running about 17%. to give you an idea of how long that is, last night at 14% my awake time was 68 minutes.

sleep is more complicated than that of course but I'm starting to think at some point we just have to temper our expectations.

post your sleep study with personal info removed and some oscar charts so folks have something tangible to comment on. your concerns may or may not have anything to do with apnea and pap, particularly since you say your apnea is well controlled. however, we we can often achieve better results than what the system considers well controlled.

you might wean yourself off the gabapentin (don't go cold turkey!) just to see if it makes a difference. most importantly, don't sleep without masking up. as you know, untreated apnea, even in just in a nap, is exhausting. using the machine shouldn't be uncomfortable. if it is, you may have pressure setting or equipment issues.

[Geer1]

I personally don't believe psychological components are beyond this forums scope and know there are a few forum members myself included willing to try and help on all fronts as possible.

Cipralex, Trintellix, Pristiq, Clonazepam, Melatonin, Magnesium, Buspirone, Dayvigo, Valerian, Sam-E and more are meds/supplements I have personal experience with. Have also performed significant research on anxiety and depression, counseling, cbt, tried meditating etc.

Although this forum is primarily focused on PAP treatment I personally believe many if not most PAP patients suffer from more than just apnea and that if we want to better understand and treat our underlying symptoms of tiredness and fatigue it can require knowledge of far more than just PAP. It is easy to find sources for single issues (PAP, PLM, depression etc) but the hardest part is always figuring out the puzzle as a whole and the only way you can ever do that is by looking at each and every piece and figuring out how they all go together. If you try to solve a puzzle in sections you will never finish especially in cases like sleep, tiredness and fatigue where all the puzzle pieces are often intertwined and treatment for one issue can be counter productive for another.

In my specific case I recently started to look back at a couple summers ago to try and understand why I started to feel better back then (better than I do now or did all last year). That is the time I went dairy free which I know made a big difference. It is also when I started other digestive treatments which I believe helped (still think that this might be part if the picture but stuck not knowing what to try further). One other thing I had written off from that time but am now reconsidering is that I was using the pristiq at that time. I originally wrote it off after quitting cold turkey and feeling good (arguably my best in years) for another couple months. Looking back I now wonder if I did benefit from it and that my body just slowly transitioned after a while being off it. I brought it up with doctor and we plan on trying it again after I finish a couple current trials.

One interesting thing about that time is that I had more energy and was feeling better but I wasn't sleeping as good or as much. I was on the road and having to be up early most mornings and often wasn't getting 8 hours of sleep. A lot of the time we correlate tiredness and fatigue with sleep issues but if I have learned anything through my journey it is that sleep is only part of the picture when it comes to tiredness and fatigue.

Based on other comments I would consider trying a different sleep aid than gabapentin to see if that makes any difference. Dayvigo is a newer interesting one that I am currently trying.

As for the removal of mask in the morning I sometimes do that as well. Part of me believes I do it because of the noise etc during late morning light sleep. It is one thing I haven't had an issue with while trying the dayvigo (one of my recent problems has been sleeping too much but part of that is on purpose while recovering from a neck injury).

[Ratchick]

Re: Gabapentin - I would say that even if it doesn't cause respiratory depression, I was so unbearably drowsy on an even lower dose than yours that I would literally be passing out asleep midsentence, or standing up - so it's definitely possible that it's not helping with the drowsiness in the day.