When I tell people I’m a sleep specialist, many want to share stories about their sleep. I love it! I meet fascinating people living awesome lives and I learn some very interesting things about most of the people in the room. I enjoy a unique opportunity to learn about the lives of others, learn some DIY tips for treating insomnia and I love sharing what I’ve learned through years of helping people sleep better.
This holiday season I met many people willing to share stories about their sleep but I want to share one story in particular. I want to share this story because so many people may have a similar story: “I told my primary care doctor about my sleep problems and the doctor prescribed Ambien. “
This is not a post about Ambien (zolpidem) Lunesta (eszopiclone) Sonata (zaleplon) Restoril (temazepam) , antidepressants used as sleep aids such as trazodone (Desyrel), or any other particular sleep aid including over the counter sleeping aids most of which include antihistamines. This post is about all sleep inducing aids including the most commonly use DIY sleep aid, alcohol.
First let’s understand, a little alcohol has helped many people get a restful sleep and there is a time for prescription sleeping pills. Among patients referred to me Ambien is one of the most commonly prescribed sleeping pills. Ambien comes in two forms: immediate release and extended release. There are several FDA approved prescription sleeping pills and frequently doctors use medications that are not FDA approved as sleep aids because the side effect of the medication is sleepiness. This is referred to as using the medication “off label”. Sometimes using medication off label allows the doctor to treat insomnia and a comorbid medical condition. For example, gabapentin may be prescribed to control pain but because it causes drowsiness, it may also treat comorbid insomnia. If your sleeping pills doesn’t improve your sleep or you are using sleeping pills for extended periods of time, you need to be evaluated by a sleep specialist.
I met an interesting older lady at a holiday affair. She shared her difficulties with getting a good night’s sleep. “My doctor gave me Ambien but I try not to take it every night.” I couldn’t help but notice several physical signs that could be associated with obstructive sleep apnea. She was an older lady who looked to be postmenopausal age. Before menopause, due to the protective factors of estrogen, obstructive sleep apnea occurs less frequently in women. The game changes with menopause. When estrogen declines, obstructive sleep apnea syndrome occurs at the same rate in women as it does in men.
With age, not only do women lose estrogen, we lose muscle tone. Just like the muscles of the arms and legs become a little flabby with age, the muscles in the airway become flabby. These flabby muscles don’t do a good job of holding the airway open. Over the years I’ve seen a number of young patients with all the signs and symptoms of obstructive sleep apnea but the polysomnogram (a detailed sleep test) did not document apnea. I attributed this to excellent muscle tone that keeps the airway open in younger patients at risk for OSAS.
As I looked closer at my new friend, I noticed a deviated nasal septum and asymmetric nostrils. Turns out she had broken her nose on at least three different occasions. The nostrils are the first part of the upper airway. Anything that blocks the upper airway can cause sleep apnea. Her surgeon had had some difficulty repairing her nose. There was a nodule near the nasal bridge and damage to the tip of the nose.
Although she was not overweight, she had multiple signs and symptoms of obstructive sleep apnea. I suggested she immediately stop taking Ambien and have testing for sleep apnea. I also explained that continuous positive airway pressure therapy (CPAP) may not be recommended for her because of anatomic nasal obstruction.
CPAP therapy consists of using room air under pressure to support tissue of the airway and keep the tissue from collapsing. There are few contraindications to CPAP. However, nasal obstruction is a potential contraindication. If the airway is completing blocked by bony tissue, enlarged nasal turbinates or polyps it may be difficult to use air to splint the airway open. Under these conditions, the pressure required to open the airway is so great that the patient cannot tolerate the pressure. I have used a combination of CPAP and an oral appliance in some patients with nasal obstruction who did not want to undergo surgery but the best treatment in this type of case is to correct the airway surgically.
I told her that she may be waking up due to a lack of oxygen caused by OSAS. To continue sleeping through severe oxygen desaturations would put her at risk for a heart attack or stroke. Until she can get to her doctor, sleeping in a recliner might help keep her airway open and improve her insomnia.