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Rating Your Sleep Night after Night with PAP Therapy: Useful Practice or Futile Exercise?

From Classic Sleep Care

I rate my sleep nearly every morning. Though it is mostly a mental check born of obsessive-compulsive tendencies, it nevertheless surprises me how much information I gain by taking less than a minute to clarify the good, the bad, and the ugly about my last sleep period. Usually, my shorthand approach is to give my sleep a rating on a 0 to 100% scale, but the meaning behind these percentages is what has served me repeatedly to recognize problems and their ultimate solutions.

The two main ways in which I use my scale is to awaken and within minutes ask myself how well I slept with particular attention to the sensation of having slept deeply or not. I also think about how much dreaming occurred and whether I recall any interruptions from the night’s slumber. This information is usually so reliable I can predict beforehand to what extent my ASV PAP device will register residual breathing events or elevations of leak, both of which provide a factual basis for measuring the quality of that night’s sleep. If I feel very refreshed and recall the sense of very deep slumber combined with a memory of intense dreaming, then I expect the data on the device’s LCD to show breathing events between 0 to 0.2 and a leak in the 2 to 4 lpm or less, sometimes 0.

As you may recall from other posts, I put less stock in the duration of hours slept compared to the quality of sleep. So, the number of hours that typically shows up ranges between 6.5 and 7.5 hours, but the range infrequently may run between 5.5 and 9.0 hours. These numbers do not reflect important information unless there is an obvious disturbance that interrupted sleep. If the sleep lab calls, and I need to monitor a cardiac arrhythmia and discuss plans with the sleep tech, I recognize fewer hours slept may affect functioning the coming day. However, a night of interruptions is far less common than climbing into bed, saying my prayers and falling asleep within minutes, and then waking up in the morning without an alarm between 6.5 to 7.5 hours later and not recalling any interruptions except an occasional recall of pillow or mask repositioning, lasting no more than a few seconds of consciousness. Continue reading “Rating Your Sleep Night after Night with PAP Therapy: Useful Practice or Futile Exercise?” »

New Policy: Minimum of Seven Hours of Nightly Sleep

From Classic Sleep Care


The American Academy of Sleep Medicine (AASM) has recently introduced a new “consensus statement” that recommends 7 hours of sleep at night as the minimum duration for an adult. The basis of this consensus statement is a vast array of research that indicates fewer than 7 hours is associated with a huge number of medical and psychiatric symptoms.[1]

To understand the value of a consensus statement, it is important to know that the highest levels of evidence (e.g. randomized double-blind, placebo controlled trials) are not routinely used to make consensus statements. If the highest levels of evidence were available on the number of hours of sleep needed, then the AASM would not be publishing a consensus statement. Instead, it would publish a practice parameters article and issue a new “standard” for the field, because standards are determined only with the highest quality research in which the results essentially prove the point investigated (e.g. using PAP therapy regularly reduces daytime sleepiness; thus, PAP therapy is a standard in the field to treat sleepiness related to sleep apnea). When evidence falls below that of a standard, the next level down is a “guideline,” and when evidence falls further, below that of a guideline, it is an “option.” Consensus statements could technically be described as something below all three of these categories; then again, a consensus statement may be listed in a practice parameter to clarify an approach to treatment.

Clinical practice guidelines, a general term for the various categories described above have come under a great deal of scrutiny in the past decade for several reasons, including a “lack of transparent methodological practices, difficulty reconciling conflicting guidelines, and conflicts of interest.”[2] In addition, various bias may influence the development of guidelines wherein a certain approach to care may have gained “eminence” in its field despite a paucity of “evidence” to support its value.[3]

The most obvious concern regarding guidelines or consensus statements in particular is that they may be compiled by medical professionals who work closely with industry such as technology manufacturers or pharmaceutical companies. The authors of the consensus statements must declare their conflicts of interest, but it is not always clear whether these individuals were influenced more than they themselves might have realized while coming to terms with a final set of recommendations. Indeed, the greatest concern among many commentators on the topic of consensus science is the groupthink or herd instinct that may arise when recommendations are developed.    Continue reading “New Policy: Minimum of Seven Hours of Nightly Sleep” »

Bedtime Prayers and Self-Reflection to Treat Insomnia

From Classic Sleep Care

Bedtime prayers consist of many different themes, but two concepts in particular may have a profound effect on the ability to fall asleep and stay asleep through the night. The first and more obvious feeling that might arise during your bedtime meditations is a deep sense of gratitude for the things you accomplished in your day. When you grow to appreciate even the “smallest” things, like your capacity to walk and talk and eat, there is a state of consciousness you may achieve in the quiet of your bedroom where you view these mundane actions as little miracles, especially if you were to take a moment to compare yourself to someone who cannot walk or talk or eat. Even without comparisons, when you give yourself a reflective pause from the daily grind, you may create an opportunity to see how walking or talking or eating is nothing less than a miracle. After all, when you look discerningly at these actions, it may strike you as amazing that you exist inside a body that engages in so many interesting capabilities: you could walk five miles; you could converse with other humans for hours; and, you certainly could prepare interesting combinations of food and drink to consume.

When a person learns to look back on the day and appreciate every little aspect of what it means to be alive, to feel alive and to continue to be able to maintain good health, the sense of gratitude can release a tremendous amount of emotional tension, the type of tension that might otherwise prevent sleep onset or prevent the return to sleep if awakened in the night. Continue reading “Bedtime Prayers and Self-Reflection to Treat Insomnia” »

Sleep Hygiene and CBT-I: Context and Timing are Everything

From Classic Sleep Care

The good news about sleep hygiene is that if you use these steps at the right time, the benefits will prove considerable. The bad news is that many sleep patients complaining of sleep problems are offered sleep hygiene tips either at the wrong time or under the wrong circumstances. Whereas, the goal should be to steer patients toward the right sleep hygiene step at the right time. In a prior post we have already discussed some of these steps and drilled down into deeper emotional territory, which often explains the underlying reasons for someone to develop bad sleep habits and subsequent poor sleep hygiene.

Let’s start by clarifying who benefits the most from sleep hygiene steps. Sleep hygiene as a first-line and expedient therapy is usually helpful to individuals whose sleep problems are so mild they would never imagine themselves becoming sleep patients. So, if you are suffering from truly mild problems with your sleep, then reviewing a sleep hygiene checklist (there are hundreds of different versions on the Internet) may provide several useful tips.

In contrast, patients who seek care for sleep problems from sleep specialists are likely to be experiencing more than mild sleep complaints. As such, these patientsdemonstrate less of a chance to make rapid gains in bettering their sleep through simplistic sleep hygiene steps. In fact, sleep hygiene could make matters worse and often does so among severely hypnotic-dependent insomniacs who seek professional help. For example, if you tell this patient to set a regular bedtime and wakeup time, which is one of the classic sleep hygiene steps, along with its variant—get 8 hours of sleep each night—you can see where the insomniac will be puzzled if not flustered by such a self-defeating recommendation in the context of his or her current struggle with failing medication regimens. In this instance, the individual should be told instead something quite opposite than the dictates above, because a regular bedtime is highly unlikely, and 8 hours of sleep may be out of the question. Thus, the best conversation with the patient might turn to the principles of sleep quality and then CBT-I, and possibly in the right circumstances the simple sleep hygiene step of anchoring the morning wake-up time only. Continue reading “Sleep Hygiene and CBT-I: Context and Timing are Everything” »

How to Determine Normal Dreaming Behavior

From Classic Sleep Care

Dreaming is such an unusual and awesome experience, yet many people are confused about how to interpret their dreaming behavior. While it is certainly a very complex thing to interpret one’s dreams, I am only referring to the behavior of dreaming itself. That is, many sleep disorders’ patients seem to wonder about whether or not their dreaming activity is normal.

Dreaming is clearly normal, and one common factoid commonly misunderstood is the belief you dream only in REM sleep. Actually, we dream in all stages of sleep, but REM sleep appears to create either the dreams that somehow we are more likely to remember or dreams that appear in our consciousness more vividly. Perhaps the vividness makes them more memorable. So, when anyone is talking about dreams, most of the time he or she would be talking about dreams experienced in the stage of REM sleep.

What then constitutes normal dreaming as well as abnormal dreaming behavior?

First and foremost, among those who report no dream activity, including no memory of dreaming and no memory of dream content, such behavior is clearly abnormal with the possible exception of an individual who might be so severely repressed or emotionally blocked that the mind somehow prevents the person from dreaming or any memory of the experience. Patients who suffer brain damage may also fall into this category. Whereas, the vast majority of individuals who do not remember dreaming or dream content do so because their sleep disorders are most likely kicking them out of REM sleep. Theoretically a short sleeper who tends to lop off a big chunk of REM sleep by waking after say 4 to 5 hours might also notice fewer dreams as the largest proportion of REM would have occurred during hours 6 and 7. Then again, we would want to know if there is a physiological or psychological reason for such short sleep, because most short sleepers suffer from fairly complex sleep disorders that would explain a lot about their abbreviated sleep cycles.

Continue reading “How to Determine Normal Dreaming Behavior” »