You didn’t ask for this. You probably do not even want it. Yes I know, but I promised you a primer on how to apply the qualitative and quantitative analyses of insomnia complaints. Remember, insomnia as a complaint can represent many different issues. These include difficulty going to sleep and staying asleep as well as going back to sleep after awakening or combinations of those issues. Before you can apply that information, you need a simple overview of how to consider the multiple factors that can produce difficulty with sleep.
The approach I find most helpful is based on general factors known to often cause difficulty with sleep. The categories along with a brief description are:
ENVIRONMENTAL: Environmental causes are usually recognized by the patient, but not always. Factors such as pets, spouses, lighting, thermostat settings and others are some reasons people do not sleep well.
MEDICAL: At some point almost all medical conditions may interfere with sleep. Frequent conditions are usually muscular skeletal such as injuries and arthritis. Other common, though short-term, issues include allergies and upper respiratory illnesses.
MEDICATIONS: You are not surprised to see medications, are you? Their side effects on sleep is an obsession of mine. A careful review is in order. The website has a listing under the medication tab of those and of those that frequently cause excessive sleepiness and sleeplessness.
PSYCHOLOGICAL: We all experience short term stresses and emotional upheavals that lead to anxiety and depression. Long term difficulties with insomnia can result from persistent problems with anxiety and depression. Similarly, anxiety and depression can cause difficulties with sleep. The degree of anxiety and depression needed to produce these complaints is of a magnitude that should be apparent to the patient and a perceptive doctor, though psychological issues are often difficult to assess.
HABITS: Habits can produce insomnia. Familiar to all, caffeine containing products lead the list. Less well-known dietary factors are alcohol, tea and chocolate. Not for their caffeine, but for other components. The activities a person pursues prior to sleep also can play a significant role. Food, drink, exercise, TVs and computers and lighting need reviewing.
STRUCTURE: Sleep structure refers to timing of sleep. What is the patient’s sleep duration and their time spent in bed trying to sleep? How long does the patient sleep when he sleeps well? Is the patient a night owl (likes to stay up late and wake late) or a lark (likes to go to bed early and wake early)? Are the sleep hours stable or do they change on weekends. Does the patient do shift work? How much sleep does this patient actually need? All these are factors that need to be considered.
SLEEP DISORDERS: The last category of potential issues are the disorders of sleep. Recognized disorders of sleep may produce difficulty with what a patient considers insomnia. For example, obstructive sleep apnea, thought to occur in 25% of all adults, can cause difficulty with sleep maintenance but rarely causes difficulty with initiating sleep. Restless legs and periodic limb movements need to be considered when insomnia is reported. Primary insomnia, insomnia without a known cause, is a diagnosis under this group.
Applying a qualitative and quantitative assessment allows the doctor to focus on specific areas of concern. Often, a provider will consider a patient to have primary insomnia without giving the other factors consideration. They take the patient’s complaints of insomnia – the patient’s perceptions of their sleep difficulties as insomnia – to be insomnia without a cause and proceed with medications to help induce sleep. Getting needed information from the patient is often difficult and time can limit the providers’ opportunities to explore other possible issues. For example, frequently a patient will tell me they have stopped using caffeinated products, but upon questioning, tea or energy drinks are still being used. Another major issue is medications. Patients may be on multiple medications which can produce sleeplessness or sleepiness. It can be impossible at times to separate their specific effects.Clearly identifying the details of the complaint will direct the provider to specific items to be considered for the patients diagnosis and treatment.
It is possible to identify contributing or causative factors in many patients with insomnia complaints. The qualitative and quantitative assessments often lead to specific addressable issues that can be modified or treated without the use of sleep-inducing medications. My working patterns can be summarized best in a tabular form that I have reproduced below.
When a patient’s complaints fall into one of these patterns, a more detailed history and investigation to assess that issue will follow.
And yes, Winston, I will try not to bother you with any more advice on insomnia.
RGH 29430
COMMON PATTERNS OF INSOMNIA COMPLAINTS IN SPECIFIC SLEEP PROBLEMS
Yes, that is what I said; “A problem with insomnia needs to be analyzed qualitatively.”
During my college years, I majored in the study of chemistry. The study requirements included courses in qualitative and quantitative analysis. Essentially, the study of what a substance is made of and how much of each component part is included. My comment on analyzing insomnia qualitatively means that a physician should know the components of the complaint.
The term, insomnia, has a multitude of meanings in common use as well as in medicine. The physician needs to know what the person using the term is experiencing. In essence, what are the specific issues involved? It is only with this type of clarity that the patient’s situation can be assessed. The analysis includes the effects on daytime activities and is designed for nocturnal sleepers. Those whose primary sleeping time is during the day, for example shift workers, require a different approach.
Difficulty falling asleep or initiating sleep is the most recognized problem described by the term. Defining the time required for sleep onset is the first step in assessing insomnia. A problem with sleep initiation may be someone’s sole issue or it may be just one part of the patient’s problem.
Another difficulty often described as insomnia is waking frequently during the sleep period. It is common and considered normal to wake once or twice a night. Waking more often disrupts sleep and is frequently an issue for the patient. Those with this complaint may or may not have a third type of problem, returning to sleep.
Returning to sleep after waking during your night of sleep, can be a singular issue or can be associated with other insomnia issues. Some will wake frequently while others will wake only once or twice. A problem returning to sleep can occur in either situation.
Waking earlier than desired is another issue commonly reported as insomnia. All of these complaints may occur independently or in combination with one or more of the others.
Knowledge of the effects of the sleep problem on daytime wakefulness and napping is helpful diagnostically. Is the person sleepy during the day? Do they nap? Do they nod off?
To analyze complaints of insomnia, a physician needs to understand:
Are there problems with sleep initiation?
Are there problems with sleep maintenance?
Are there problems with returning to sleep after awaking?
Are there problems with waking too early for the day?
Are there problems with daytime sleepiness?
A patient’s historical ‘insomnia qualitative profile’ information is required for accurate assessment. Unfortunately, getting the information can be difficult, time consuming and even impossible. When obtainable, it will help with establishing a diagnosis, but a pattern of difficulty does not indicate a specific reason or cause for the issues. In fact, many or most individuals will have more than one potential causative or aggravating issue.
The frequency the symptoms occur and their intensity are important in narrowing the potential reasons or contributing factors to the sleeplessness problem. How significant is each of the symptoms reported? This step is the quantitative analysis of each of these factors
Diagnostic considerations of insomnia require knowledge of the specific complaints (the qualitative analysis) and the degree to which they are present (the quantitative analysis) for assessing factors that are known to produce insomnia.
So Winston, I have returned to my youth of qualitative and quantitative analysis. A famous troubadour once penned a song; “All my life’s a circle, sunrise to sunset.” So it appears to be. I suspect this is more than you probably wanted to know. Maybe I should prepare a short primer for you on the roles of the qualitative and quantitative assessments in identifying the factors, conditions and behaviors known to produce and aggravate insomnia.
Obstructive Sleep Apnea is a very common malady. It is familiar to many and is frequently a subject of both social and medical conversations. Individuals not engaged in frequent work with Apnea conditions may be confused by its usage and rightly so. Discussions and writings about the subject can use the term with different meanings. When used by professionals, it can also be used in various ways. It has a physiologic technical meaning; it is used as a proper name of medical conditions; and, it has a common usage that is less specific.
The word – apnea – comes from the Latin and Greek languages. The Latin ‘a + pnea’ means without breath and the Greek ‘apnoia’ means without pain. The Webster dictionary defines apnea as ”Transient cessation of respiration”. Webster’s definition fits well with the current technical use of the word, but fails to show the scope of the word’s use that has increased over the past half-century with the recognition of the associated clinical conditions.
Webster’s definition fits well with the current technical use of the word, but fails to show the scope of the word’s use…
The word is used technically to label a cessation of breathing. Sleep testing, in facilities or at home, and physiologic monitoring of hospital patients can identify periods when no air is going in or out of the nose or mouth. No breaths can be measured. These events are called Apneas.
The word is used technically to label a cessation of breathing.
The addition of chest movement measurements during these apnea events further defines these periods of apnea. If the breathing efforts are persistent during an apnea episode, the event is labeled an Obstructive Apnea. If no breathing efforts are being made by the chest, the pump that moves air in and out, the apnea is caused by the lack of chest effort and is called a Central Apnea. It is called central because breathing effort by the chest is controlled, started and adjusted, by the Central Nervous System. If the breathing problem is associated with both partially reduced chest movement and total cessation of movement, it is labeled a Mixed Apnea. As we can see, the technical apnea breathing events are further defined as obstructive, central or mixed.
‘Apnea’ is used as part of the proper name of medical conditions
‘Apnea’ is used as part of the proper name of medical conditions. These conditions were described and first recognized approximately a half-century ago, but probably have been affecting mankind for our entire history. Obstructive Sleep Apnea is the first of these. When breathing is blocked or partially blocked for 10 seconds at least five times per hour, a diagnosis of the clinical syndrome of Obstructive Sleep Apnea is established.
Central Sleep Apnea is the clinical condition where the primary form of apneas measured is central. It is established when a certain percentage of the physiologic apneas recorded on testing are the central type. Central Sleep Apnea can be the result of multiple medical issues that range from cardiovascular problems to neurologic conditions. It can be rarely seen on its own and not associated with other medical problems.
A third commonly accepted diagnostic term is Complex Sleep Apnea. This diagnostic group represents individuals with obstructive sleep apnea treated with CPAP whose breathing events do not resolve when they are treated. Their Apnea Hypopnea Index remains high. However, on repeated testing with CPAP, the breathing events are now predominantly Central Apneas. The CPAP treatment caused a change from Obstructive Apnea events to Central Apnea events. This type of medical condition is called Complex Sleep Apnea.
The term Apnea Hypopnea Index (AHI) may be new to some, but it is very important that it is understood. The ‘Apnea’ referred to is the physiologic measured Apneas. ‘Hypopnea’ is a partial obstructive breathing event measured on testing. They have the same secondary effects as apnea events but without the total cessation of airflow. The AHI is a calculated number representing the total events (Apnea and Hypopneas) per hour.
The AHI is the measurement on a diagnostic sleep test that determines if an apnea condition of some type is present. With a patient on therapy, it is the number that is followed by the physician to determine how well the therapy is working. It is measured on most CPAP machines and can be reviewed by the patient on a day-by-day basis. The AHI on a diagnostic test is and has been the measurement to determine the severity of sleep apnea conditions for many years. The AHI is an example of the technical use of the word apnea.
…the common use of the term Apnea is far less specific…
Finally, the common use of the term Apnea is far less specific than the uses we have reviewed. Often, the word is used to encompass a broad range of the field. In writings and conversations, it will be used by an author as a single word to cover all, or one, of the apnea medical conditions – obstructive sleep apnea, central sleep apnea and complex sleep apnea. When discussing Obstructive Sleep Apnea conversationally, most will speak about apnea, meaning obstructive sleep apnea. The most simple descriptive of its common use is as a substitute for the clinical conditions associated with breathing problems during sleep.
What we have covered.
1. Apnea is technically an absence of breaths (no airflow at the nose and mouth).
2. Apnea, used technically, during sleep is further defined by its features to be obstructive, central or mixed.
*Obstructive apnea
*Central apnea
*Mixed apnea
3. Apnea is used in the formal name of medical conditions including:
*Obstructive Sleep Apnea
*Central Sleep Apnea
*Complex Sleep Apnea
4. Apnea, used in its technical manner, is a component of the Apnea Hypopnea Index measurement used to judge the severity of the problem.
5. Apnea’s common use is as a general term covering one or all of the clinical conditions
Many, if not most people, come to doctors, sleep doctors or clinics because of symptoms or at the request of a family member. Symptoms can be almost any issue with sleep and its quality, but nonrestorative sleep with daytime tiredness is the most common. More on that at another time. Family members often become concerned because of a person’s snoring or the interrupted breathing of a family member – a Bear in the Bedroom.
A bear you might not want in your bedroom
Snoring is extremely common with estimates running greater than 50% of some populations reviewed. Snoring is common in Obstructive Sleep Apnea and snoring is a sign of possible apnea. But, not all those individuals with Obstructive Sleep Apnea snore and not all snorers have the condition.
Well, what about a bear in the room? To be honest, I don’t even know if bears snore. The phrase, ‘snores like a bear,’ is frequently used to describe loud snorers. Loud is hard to define. One person’s loud is another person’s soft. However, if we define loud as being able to hear someone outside of their sleeping room and down the hall or up or down stairs, those folks almost always have apnea and it is usually significant apnea.
Hear Someone Snoring From Outside Their Room? They All Most Always Have Apnea!
Do you hear you mother, father, sister, brother, friend, roommate, spouse or significant other snoring from the other side of the house? They should be considered to have Obstructive Sleep Apnea until testing proves that is not the case. Loud snoring is almost always Obstructive Sleep Apnea. We’ll talk more about snoring in a future issue.
The Intermittent Bear in the Bedroom
You can hear the person sleeping. They are snoring, first softly and then more loudly. The snores develop a rhythmic pattern. They start to come and go. The pattern of noise gets your attention and keeps you from sleeping.
There is a loud, gasping, rough sounding snore or several in a row. Following these grating, rattling noises, a slow, steady, almost melodious series of snores rhythmically lull you back toward your own sleep. The snores fade and stop. You listen and hear nothing. Then, after this quiet period, the grating, gasping suddenly returns and jars you awake.
Does the above experience sound familiar? They are the sounds of obstructive apnea. The quiet period is the apnea. The person is breathing and the diaphragms are working to move air into the lungs, but the airway is closed and no air is moving. The person takes a forceful breath and the airway opens with a loud gasp.
If you have been observed to have these events, you are extremely likely to have obstructive apnea. If you have seen these events in others, they are also likely to have apnea.
Hear Someone Having Breathing Problems While Asleep? They Almost Always Have Apnea!
If you sleep in a room or home with a bear, you are sleeping with someone who probably has significant Obstructive Sleep Apnea.
What Have We Reviewed
Loud snoring is almost always a sign of Obstructive Sleep Apnea.
Not everyone with Obstructive Sleep Apnea snores.
Hearing and Observing someone with breathing problems while he is asleep is almost always a sign that he has Obstructive Sleep Apnea.
Mr. Oso. The only type of bear you want in your bedroom. (Best Friend of SPH).
Previously
Obstructive Apnea is a very common problem for humans.
Symptoms and signs are often non-specific
When sleep symptoms are present, Obstructive Apnea is often the cause.
What to Expect in Future Installments
What is Obstructive Apnea?
Why are individuals with Obstructive Apnea tired and sleepy?
Do you know what your apnea number was when you were diagnosed?
Welcome to The Sleep Center blog. I know, just what you need, another email, another electronic interruption to your life. But, with a little bit of luck you will find some pearl, some nugget, some small fact that will make you sleep better, your days clearer and life more rewarding.
Let’s start with a brief note about Obstructive Sleep Apnea. Why are doctors so concerned? Why will so much of what we talk about on these pages be related to Obstructive Apnea. I hope you know. But, if not, it is because apnea can lead to many long-term medical problems and early death. Successful treatment has been shown to reduce the apnea symptoms and reduce the long-term problems that people experience. Patients with apnea who successfully control their apnea live longer better lives.hy does your doctor focus on whether you have Obstructive Apnea? Of course it causes those nasty conditions – hypertension, diabetes, vascular disease resulting in heart problems (atrial fibrillation, heart attacks, heart failure), strokes, memory problems, and accidents – along with the possibility of dying earlier than you might want. While that is reason enough, it is far from the only reason
The reason is….
Apnea is Very, Very Common
Obstructive Apnea is estimated to occur in greater than 25% of the adult population. It is more common as we grow older. It occurs in all age groups.
Furthermore
Sleep Symptoms are often non-specific
Many symptoms can result from apnea. Similar symptoms can result from other disorders of sleep. As a result, testing is almost always required to exclude Obstructive Apnea as a cause of a person’s symptoms.
A problem with your sleep may result from more than one problem. It is not uncommon for a person to have sleep problems and be found to have Obstructive Apnea on sleep testing. After being treated, usually with positive airway pressure, the doctor says the treatment is working well. The apnea is corrected. But the individual feels no better. Apnea is so common that it is frequently discovered and diagnosed when other sleep problems are also present and those problems are causing the symptoms. Treating the apnea is still important for the majority of these individuals because of the significant long-term complications of Obstructive Apnea.
The reasons the doctor is worried about obstructive sleep apnea are
Obstructive Apnea is a very common problem for humans.
Symptoms and signs are often non-specific
Obstructive Apnea causes many long term medical problems
