Sleep apnea is an under recognized contributor to heart disease, high blood pressure, insulin resistance, metabolic syndrome, and depression. Most individuals cannot tell if they have sleep apnea themselves other than maybe constantly feeling tired or falling asleep accidentally while sitting still. Sometimes spouses are ‘kind’ enough to disclose their partner’s sleep habits (or even video it for their own nefarious purposes).
Sleep studies are a simple and effective means to diagnose sleep apnea and disordered breathing. In years past this meant a one to three night stay in the hospital with an associated $3000 per night bill. Now we have reliable home testing equipment. The latest guidelines validate that home testing is an appropriate method for many patients.
Trinity Medical Associates has had a partnership with a sleep study company that offers our patients a clear upfront price of $250 for three nights of home study. They are happy to process the claim with a patient’s insurance company who may pay for some or all of the test depending on the policy. However, the maximum out of pocket cost for any patient regardless of insurance coverage is only $250. That is a great bargain when compared to in hospital testing for a single night.
If you are interested in discussing poor sleep and excessive sleepiness or would like to set up a home sleep study, please give us a call to schedule an appointment. Sleep is a critical pillar for our best health. You won’t believe the difference good sleep can make.
Sleep – at its best it’s a wonderfully refreshing period where we physically and emotionally get reset for another day. But for an estimated 70 million Americans, one of the over 80 different sleep disorders intrudes on their ability to get a good night’s sleep. Everything from sleep apnea to restless leg syndrome to simple insomnia is included on the list. For our purposes today, we want to look under the covers at insomnia, defined as difficulty initiating or maintaining sleep resulting in daytime impairment.
About 10% of the population would fit the criteria for some level of chronic insomnia, hence the 60 million prescriptions yearly for sleep aids. And this doesn’t include the raft of over-the-counter sleep meds that fly off the shelves.
So is insomnia such a big deal? Well, yes, it is tied into several serious illnesses. Those with insomnia are twice as likely to have congestive heart failure, five times as likely to have anxiety or depression, and have increased rates of diabetes, obesity, motor vehicle accidents, infections, and have impaired memory, thought, and work and school performance. Of course some of these are effects of the insomnia and some are causes.
How much sleep do we really need? The average person needs 7 to 9 hours of good quality sleep. But the average American gets 6.9 hours, leading to a lot of sleep deprivation and all the baggage that comes with it. Some individuals are in bed long enough but don’t wake up refreshed and rested. This often indicates a poor quality of sleep, either through frequent awakenings, sleep apnea or some other sleep disorder that intrudes on the benefits of their sleep.
What are some of the causes of insomnia? For some, it is a built-in condition with a nearly life-long pattern of poor sleep-wake cycles. But there are a number of factors that can worsen the problem. Not surprisingly, children with smart phones, televisions or computers in their bedrooms are generally found to have poorer sleep patterns than those who do not. Certain medications, such as decongestants or corticosteroids can cause insomnia. Even meds that are used to induce sleep, such as antihistamines, can cause an opposite effect in a percentage of individuals, causing prolonged wakefulness.
So, to cut to the chase, what can you do if you notice that you are not sleeping well? Perhaps you awaken unrefreshed and have some daytime sleepiness. First, tune up your sleep habits. In general:
avoid daytime napping
avoid caffeinated drinks after lunch
get some physical exercise or exertion in (preferably early in the day)
try to go to bed at approximately the same time daily
don’t watch TV or read in bed
give yourself a set amount of time (perhaps 20 minutes) to fall asleep
if you don’t fall asleep in the set time, get out of bed and read in a chair until you feel you may be tired enough to sleep. Then get back into bed and give yourself 20 minutes again.
If after 1-2 weeks of this approach you aren’t seeing good results, you may benefit from consulting your physician. Certain medications may be an issue, or health issues such as hyperthyroidism, anxiety or depression.
If other issues are ruled out and the problem is persisting, prescription sleep aids can be considered as well as something called cognitive behavioral therapy, though this can be harder to access. Sleep meds include everything from the well-known Ambien (zolpidem) to sedating anti-depressants such as trazodone, antihistamines such as diphenhydramine (Benadryl), to benzodiazepines such as temazepam (Restoril), and even stronger, less-often-needed meds such as Seroquel. Incidentally, it was recently found that for females the 10 mg. dose of Ambien was associated with a 30% higher incidence of motor vehicle accidents the next morning. This led to the recommendation that women limit their Ambien dose to 5 mg, especially if they will be driving the next morning.
Over-the-counter meds such as Tylenol PM and Advil PM often use the sedating antihistamine, diphenhydramine, which leaves many with some left over morning grogginess. Melatonin has been found to be mildly effective in shift workers, but not very effective for typical insomnia. And the list goes on.
The bottom line is that there are pros and cons to each treatment option, including the option of just trying to ignore this problem and not treat it. So if insomnia is plaguing your nights, it’s worth some attention. Good sleep and good health tend to go together.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835
Over prescribing of ADD and ADHD stimulant medications, especially in adults, is a rapidly exploding issue. Inappropriate use is common at many universities and high pressure jobs. However, there remains a considerable number of patients who have legitimate need and should be cared for within the healthcare community.
Addressing a patient’s need for stimulant medications requires a careful and thoughtful approach. For many disorders, Trinity uses our multifaceted approach to therapy which so often improves, reverses, or even cures the common maladies of modern humankind. We address the three main pillars of health that are required for any person to be remain healthy: good nutrition, good exercise, and good sleep.
Nutritionally, studies have demonstrated that a lower carbohydrate dietary plan improves ADD/ADHD symptoms over other dietary interventions. Omega-3 fatty acids found in fish oil (or actually eating more fish) is one of the few supplements that improves ADD/ADHD symptoms. Vigorous aerobic activity consistently demonstrates improved symptom control especially if challenging tasks are performed within the 90 minute golden window following exercise. Finally, sleep is a critical element to good focus and concentration. Disorders such as sleep apnea, excessive screen time, as well as burning the candle at both ends severely limits the brain’s ability to concentrate for weeks and months on end.
Trinity has adopted the widely published guidelines from the American Academy of Pediatrics and the American Academy of Family Practice concerning the prescribing of stimulant medications These guidelines include such things as the following:
-Stimulants will only be prescribed after an appropriate history and physical is performed which supports the diagnosis
-Secondary causes for the symptoms including poor nutrition, poor exercise, and poor sleep have been fully addressed
-Follow up is required in person on a monthly basis until stable then every three months thereafter
-Medication changes are done in person only
-Regular use of Tennessee’s Controlled Substance Monitoring Database
-Refills are done on time. They are not filled early, after hours, or for long term supplies.
-Urine drug screens are required at random intervals to confirm the use of the prescribed medication as well as the absence of inappropriate chemicals.
-Long term prescribing of medications is not guaranteed and referral to a mental health specialist will be made if the situation warrants.
We feel that with our approach and the use of these guidelines we will continue to provide high quality care for individuals in need and limit the inappropriate use of these medications.
Mr. Beeler, a fiftyish guy was perplexed and worried: “I just don’t get it. My mail box is maybe a hundred feet down the driveway. Used to be nothing to march down to it, grab the mail and hoof it back and never think about it. Then I started getting a bit winded on the uphill walk back. Now I’ve got to stop once on the way down and two or three times on the way back up to catch my breath. I’ve never even been a smoker; what’s the deal?”
Ok, this one is a bit more complicated, but common enough to be worth knowing something about. Pulmonary hypertension (PH), which is what Mr. Beeler ended up having, is where the blood pressure in the lung part of the circulation has become elevated. So, what does that do? That means the part of the heart that has to pump blood through that higher pressure system has to work harder. Over time the blood vessels change in ways that cause oxygen to be picked up more and more poorly by the lung’s circulation. Likewise the right side of the heart that serves as the pump for the lung circulation can get weaker and weaker.
A person developing PH may notice that it takes less and less effort to make them feel quite short of breath. They may also notice fatigue, chest pain with exertion or even passing out with exertion. Often they end up needing to be on oxygen to keep their blood oxygen level normal.
The causes of PH are quite varied — everything from heredity to COPD (chronic lung disease) to various heart conditions to a range of medicine and toxin side effects to a further laundry list of causes. While it is relatively rare in otherwise healthy folks, it can afflict up to 1/4th of people with COPD and one out of five with sleep apnea, just to name a couple of diagnoses.
It is often the shortness of breath that eventually brings people in to get checked by their doctor. The high pressure in the pulmonary (lung) circulation is often noted on an echocardiogram (an ultrasound of the heart). Other tests such as a heart cath, if needed, can be even more definitive.
Treatment for PH can be challenging. If there is some specific cause found for it then treating that underlying cause may help. If it is determined that the PH seems to have developed without some other trigger then there are a number of other treatments that are sometimes helpful in reducing the pressure and improving oxygen levels. One treatment even involves using the active ingredient in Viagra. At the far extreme of treatment, lung transplants are occasionally undertaken. Obviously along the way having a specialist involved can be vital.
So, worsening shortness of breath with exertion is never something to be ignored. And getting it checked sooner rather than later can sometimes make a significant difference in the success of treatment with several of the causes, including the complicated problem of PH.