Archive for the ‘Sleep Disorders’ Category

I have had chronic sleeping problems for 10 years. I am a 58 yo woman going through menopause. My mother is 90 and still on sleeping pills. Could my condition be hereditary? Which pill will give me 7 hours of sleep leaving me refreshed the next day?

See the Do’s and Don’ts of sleeping habits on my site:   

 http://askdrjones.com/wp-content/uploads/2006/06/sleep_dos_and_donts1.pdf

Make sure you are doing all the cognitive and behavioral things you can do to optimize sleep. 

You are in a high risk group for insomnia.  Sleep problems are more common in women than men, increase with age, and are aggravated by menopause.  The onset of your insomnia coincides with perimenopause.

Estrogen has many more potential benefits than risks for most women – especially brain benefits.  Unfortunately, if you still have your uterus you have to take some progesterone.  There are options like long acting intrauterine forms of progesterone that can minimize side-effects.  I am totally opposed to oral estradiol such as Estrace.  http://test.askdrjones.com/2007/04/28/say-goodbye-to-the-pill-ladies/

  Premarin or synthetic Cenestin by mouth and or estradiol cream/gel or patch is the best form.  The WHE study 5 years ago scared a lot of women about estrogen replacement therapy but the women in the study were on average 10 years post menopause and never used estrogen – that puts women at greater risk and may apply to you especially if you smoke.

One milder option is prescription DHEA which in women mainly turns to testosterone (good for bone and muscle) but then in the brain is converted to estrogen – avoiding the increased risk of estrogen related breast cancer.  

There are occasional women who benefit from natural progesterone (Prometrium) at bedtime since it has a natural benzodiazepine like sedative effect.  I recommend that you don’t take synthetic progesterone like Provera.  

Any form of alcohol can contribute to sleep problems because it causes arousal as it wears off.  If you do drink alcohol make sure it is not within 3-4 hours of going to bed.

We are fortunate to have very effective sleep medications that provide normal sleep.  The mildest, shortest acting is Sonata, usually 10mg-20mg lasts 4-5 hours.  Benzodiazepines such as Xanax, Klonodine, Ativan, etc., shouldn’t be used at bedtime because they decrease stage 4 sleep (the most important type of sleep), but they can be used for early awakening with inability to get back to sleep – since we get all our deep sleep in the first three hours.

Lunesta (2-4mg is needed) for sleep but may cause a bad taste in 15-20% of people (less likely if taken with orange juice).

In general, Ambien CR is better than Ambien tablets because they frequently don’t last long enough.  The generic form is probably weaker.  The CR form is not as strong as the tablets for inducing sleep but lasts longer.  Some people have to combine CR with the short acting tablets to get to sleep.

All of these sleep medications work better on an empty stomach – combined with good sleep habits as I stated earlier.

Circadian rhythm problems can also contribute to the problem.  Morning bright light and or evening melatonin or prescription Rozerum may also help. 

Adding Tenex or Clonidine, or occasionally Prozosin can be helpful.  Trazodone, Seroquel, or low dose Doxepin may help.  Neurontin (up to 800mg) or Lyrica also induce normal sleep.

Chronic insomnia can be very resistant because of all the anxiety and conditioned negative expectations.  It is harder to treat initially and gets easier as fear of insomnia subsides.  When problems persist a sleep study can help identify problems such as restless legs, myoclonus, or sleep apnea.

When all else fails there is a medication that usually works, Xyrem.  It is highly regulated because of previous misuse of it as GHB.

Because good sleep is so essential you have to persist until you find what works for you.  Don’t give up until you find the right medication at the right dose.    

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Does Xanax work for sleep?

I am not crazy about long term use of Xanax (or any other benzodiazepine) for treatment of chronic insomnia because they don’t produce all the normal sleep states (esp. stage 4 deep sleep).  Whether this is the case in everyone and whether this effect persists indefinately has not been adequately studied.  My main concern is that lack of stage 4 sleep can be associated with less secretion of growth hormone and other restorative processes that occur during the deepest sleep states – e.g., maintaining the immune system.  There may also be some reduction of REM sleep – that might impair long term memory.  None of this is adequately studied.

 
Xanax is a great medication for anxiety and can be used long term – but I prefer that it not be the primary medication for insomnia.  Ambien CR, Lunesta, Sonata, or regular Ambien provide normal sleep.  Tenex (Guanfacine) or Clonidine help induce deep sleep.  Trazodone and Seroquel in low dose seem to provide relatively normal sleep although they are stronger meds and have other potential side effect issues.
 
Rozerem, a prescription med that stimulates specific Melatonin receptors associated with sleep problems (mainly with circadian rhythm problems) is also a possible solution.
 
Before considering any sleep meds, sleep habits (See Do’s and Don’ts of Sleep on my website) need to be addressed.  One of the biggest causes of sleep problems is inadequate am bright light, and too much bright light at night (especially TV and computer screens).
 

 

 

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You Can’t Have It Both Ways

Give me something to fix my problem. Don’t give me anything that could ever cause any side-effects …

Fortunately most people are fair and reasonable. They know anything strong enough to significantly change brain functioning, put you to sleep, stop panic attacks or anxiety, relieve depression, or improve focus and motivation has to be strong enough to sometimes cause side-effects. The infinite variety of genetics that helps make each of us unique can cause a myriad of idiosyncratic reactions to medication.

Case in point. “Perchance To … Eat? A few Ambien users find themselves at the fridge” was an article in Newsweek, March 27, 2006. The story is about a woman who was sleepwalking and bingeing during the night. She found out online that other people taking Ambien were having this problem. A New York attorney has filed a class action suit on behalf of 300 patients who complain of similar problems or of doing things while sleepwalking that are dangerous, like driving a car. Most or all of these people apparently have a history of sleepwalking.

Sleepwalking occurs during deep, stage 4 sleep. Ambien (and other sleep medications Lunesta, Sonata) help restore normal sleep, which includes deep sleep. Twenty-six million prescriptions were written in the U.S. last year for Ambien. Since this case was reported 2-3 weeks ago, prescriptions have been falling off.

In our litigious society, there is a history of overreaction where the benefits of the many are lost because of the misfortune or idiocy of the few (or sometimes the one).

For any given medication, there are literally hundreds of possible side-effects, including those that are rare (defined as less than 1 per 1,000). The massive amount of information makes it difficult to find the important, relevant information.

Common side-effects are usually due to

  • over-shooting the blood level in search of the “right dose”
  • common genetic variants
  • combining different medications
  • or many other possibilities

In making a joint decision to try a medication, a doctor and patient consider potential benefit vs. potential risk. It’s not fair or reasonable to say after a rare side-effect “this medication shouldn’t have been prescribed.”

If we use the principle, “don’t prescribe any medication that can ever cause a potentially serious side-effect,” we might as well close the pharmacies. Anaphylactic reactions to penicillin are a case in point. While we’re at it, let’s also get rid of shell fish, peanuts, and strawberries.

There has to be a reasonable balance. On the one hand, the Hippocratic Oath is, “first do no harm.” On the other hand, surgeons are told if you never remove a normal appendix you are being too careful – dangerously cautious. Waiting until an appendix ruptures while waiting to be certain will jeopardize a life. The best mantra is, “benefit vs. risk.”

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Rozerem: A Novel Treatment for Insomnia

A new treatment was recently approved by the FDA for insomnia. Rozerem (Ramelteon) has a different mechanism of action than other sleep medications. It works by stimulating two of the melatonin receptors in the brain. It does not stimulate the melatonin receptor that can constrict arteries and so therefore should not have the potential risks associated with high doses of melatonin.

Since melatonin is a natural hormone that induces sleep, Rozerem should produce normal sleep. It has been shown to induce the normal sleep stages of EEG. Rozerem is not structurally or chemically related to melatonin. Melatonin is a much simpler structure and is derived from serotonin.
Studies have shown Rozerem (on the market as 8mg tablets) to be better than placebo at helping people stay asleep. It has a fairly short duration (1/2 of it is gone within 1-2.5 hours). My guess is that it is especially helpful when the sleep problem is related to the circadian rhythm being off – i.e., the normal melatonin peak being either early or more likely late due to lack of adequate am bright outside light exposure. Shift work and other irregular sleep schedules can also interfere with normal physiology of sleep.
Rozerem may be particularly helpful in adolescents – who don’t usually do well on typical sleep medications. It may also be helpful for insomnia in the elderly who have reduced melatonin (that usually peaks in the late afternoon or evening).
Rozerem probably won’t be helpful for severe insomnia or insomnia associated with anxiety or mood disorders. Development of tolerance hasn’t been seen but we don’t have very long studies. It may be helpful added on to other sleeping pills when they are not fully effective.
One concern is that melatonin can increase prolactin and decrease testosterone/estrogen levels. This effect has been reported in an occasional patient on Rozerem. Complications of this hormone effect could be decrease in libido in the short term but long term cause other physical problems.

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How To Take Sonata (Zaleplon)

SONATA (Zaleplon)

Sonata, available in 5mg and 10mg capsules, is a sleeping medication from a class of drugs known as nonbenzodiazepine hypnotics.  Insomnia is usually due to hyperarousal.  Sonata works by enhancing the brain’s natural tranquilizer called GABA.

GETTING STARTED

Take one 10mg capsule after going to bed if unable to sleep using good sleep habits.

Note: Take 1-2 hours after eating, or 3 hours after eating a fatty meal.

20mg may be needed initially if:

  • Switching from another hypnotic
  • Under very high stress
  • High tolerance to medications

Most patients can decrease to 10mg after 4-7 days.

SONATA MAY NOT BE NEEDED EVERY NIGHT

  • There is no “rebound insomnia”
  • It can be taken up to 4 hours before rising

Note: A common complaint is that some people wake up after 4 hours. If this occurs, the dose can be repeated. This is usually due to hyperarousal and after a few good due nights of sleep, repeat dosing is not needed.

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VIDEO: Dr. Jones on Sleep

In this video clip, Dr. Jones says sleep is the most important factor of managing stress. But, how can you get quality sleep every night? What options do you have? Watch this clip to find the answers to these questions … and more …

Watch the Video

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Why Can’t I Sleep And What Can I Do About It?

As a part of National Sleep Week the National Sleep Foundation just released the results of a new survey. They found that 75% of American adults have at least one symptom of a sleep problem and 25% have symptoms at least several times per week that cause problems with daytime functioning. Insomnia is defined as problems with either falling asleep, staying asleep, or early morning awakening that causes next day consequences like excessive fatigue, daytime sleepiness, poor concentration and/or irritability.

Why are so many people having problems? A physician friend of mine told me recently that he’s reluctant to treat insomnia since it’s just a symptom of depression. But is this true? It is according to the old paradigm, but now we know it’s usually the opposite. The new paradigm is that untreated insomnia causes depression. Of course depression worsens insomnia and then they both snowball. It’s the chicken and the egg.

One study found that only 16% of patients with insomnia were depressed. Another 24% had an anxiety disorder. But 60% had other causes of their sleep difficulties. Many things can cause problems with sleep on a frequent or nightly basis. The most obvious is high stress.

Many medical problems especially chronic pain, gastro esophageal reflux, heart disease, respiratory illness – in fact just about any chronic illness has a negative effect on sleep. Many substances including alcohol, tobacco, and caffeine can cause problems as a direct effect +/- as a rebound effect. Changing schedules, shift work, and jet lag disrupt normal sleep patterns. Specific sleep disorders like restless legs or myoclonus (muscle jerks during sleep) – usually noticed more by the bed partner are common.

Sleep problems tend to increase with age. 50% of the elderly experience significant sleep problems. Women have more sleep problems than men, especially premenstrually, during pregnancy, post partum, perimenopause, and menopause. As if all that is not enough many of the medications that we take worsen sleep, including antidepressants, stimulants, cardiovascular, respiration medications, and others. Medications may interfere with sleep directly and/or cause rebound symptoms as they are wearing off.

Fortunately we have excellent medications for treating insomnia. I believe everyone needs to have available a safe/effective sleep medicine to take at least on an as needed basis. Just this week, we now have a new sleep medication, Lunesta. This new medication might be good for those that don’t have success with Ambien or Sonata. Some people wake up in 3-4 hours when taking Sonata, or wake up in 5 hours when they take Ambien. Lunesta lasts significantly longer and is more likely to provide 7-8 hours of sleep. Lunesta was also well tolerated in research studies. I will still need to see how it works in the real world before we can whole heartedly endorse it. Also, this summer a controlled release Ambien is coming out. This will presumably increase duration of action.

Unfortunately only 7% of people with sleep problems go to their doctor to get sleep medication. Of people with sleep problems who are seeing a doctor for another reason only 1 out of every 3 will bring it up. How amazing is that? 2 out of 3 people with insomnia don’t discuss it with their doctor or ask for a sleep medication.

Insomnia hurts mental and physical health. It interferes with work, study, relationships and hobbies. It reduces quality of life. Insomnia is usually easily treated. The sleep medications Lunesta, Ambien, and Sonata not only are safe and effective but provide normal sleep – both deep sleep and dream sleep. Benzodiazepines like Xanax decrease deep sleep. Antidepressants decrease dream sleep. OTC’s (antihistamines) don’t provide normal sleep and are more likely to have next day side effects. Of course, not every sleep problem requires a sleeping pill. Sometimes cognitive behavioral changes are adequate. See the Sleep Do’s and Don’ts Handout

Why are so many people hesitant to ask for or use medication for sleep? It may be that the importance of insomnia is trivialized or that people are afraid of becoming hooked on “sleeping pills” or still have the old stigma of addiction (associated in the past with barbituates and benzodiazepines).

Current sleep medications, Ambien, Sonata, and Lunesta have a very low abuse potential. Addiction means compulsive use despite negative consequences. This is almost non-existent with the new sleep medications. Physical dependence means physiologic adaptation resulting in serious withdrawal symptoms if a medication is abruptly stopped. This is also extremely rare with the new sleep medications.

As always we want to compare possible risks with probable benefits. This one is a no brainer. Do whatever it takes to ensure quality sleep every night. Your health and longevity depend on it!

 

See Sleep Newsletter

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Sleep Meds: Addiction vs. Physical Dependence (audio clip)

Have you ever heard someone say, “I don’t want take that medicine … I might get addicted.”? Did you know there is a difference between “addiction” and “physical dependence”? Listen to Dr. Jones’ explanation.

[Audio clip temporarily unavailable]

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Quality Sleep Every Night

Even with the best sleep habits everyone has trouble sleeping on occasion. Almost everyone would benefit by having medication available that safely provides good quality sleep.

Our internal clock (circadian rhythm) is regulated by bright sunlight. Even on cloudy days, it is at least ten times brighter outside than indoors. Bright light suppresses melatonin, (the body’s natural sleep inducing hormone). As evening approaches and light diminishes, melatonin increases. Under these conditions, melatonin peaks around 9:00p.m. Ideally, this would make going to bed at 10:00p.m. and waking at 5:00 or 6:00a.m. a healthy sleep schedule. Going outside for the first time at noon will set your sleep clock for 16 hours later, or 4a.m. This makes it very difficult to fall asleep even at normal bedtime.

Some individuals, especially the elderly are “phase advanced.” This means melatonin peaks in the late afternoon, causing sleepiness. Even if going to bed is delayed, they often wake up in the middle of the night. They usually fall asleep in the early evening and then wake up 7 hours later at 3:00-4:00 a.m. They complain of not sleeping through the night, but are actually getting plenty of sleep.
This is helped by:
• Getting late afternoon sunlight
• Melatonin (see below) intake in the morning
• Minimizing morning bright sunlight
Others, especially teens and young adults tend to be “phase delayed.” Phase delay may be due to lack of morning bright light, lack of any exposure to outside bright light, and excessive evening artificial light. They also tend to stay up late, even when they must get up early the next morning. Their melatonin peak is delayed to midnight or later.
This is helped by:
• Getting bright morning sunlight
• Melatonin (see below) intake in the evening
• Minimizing afternoon bright sunlight
Melatonin comes in 3mg tablets.
Starting dose-1/4 tablet sublingually 3 hours before bedtime if phase delayed. If phase advanced, take in the morning.

Increase the dose to 1/2-1 if needed.

This does not help sleep associated with hyper arousal. However it can help with jet lag, shift work, or changing the internal clock.

Another option is to use an artificial full spectrum, bright light. These can be purchased by companies such as Sunbox Corp (www.sunbox.com.)

Can you sleep too much? Yes! Since after 7 1/2 hours sleep you are getting almost all REM sleep, which uses MENTAL energy, you end up more sluggish.

What’s the difference between sleep and fatigue?
Sleepiness is improved by either a nap or vigorous physical activity, fatigue is not.

People who live long, healthy lives have good sleep habits. It is like regular car maintenance. “Pay me now, or pay me later.” You can “make up” 6-10 hours of sleep loss, but each day after inadequate sleep you will have higher levels of stress hormones and potential detrimental affects to your health. Make the time to sleep 7 hours every night, or subject your body and brain to increased wear and tear.

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Quality Sleep Every Night

Even with the best sleep habits everyone has trouble sleeping on occasion. Almost everyone would benefit by having medication available that safely provides good quality sleep.

Our internal clock (circadian rhythm) is regulated by bright sunlight. Even on cloudy days, it is at least ten times brighter outside than indoors. Bright light suppresses melatonin, (the body?s natural sleep inducing hormone). As evening approaches and light diminishes, melatonin increases. Under these conditions, melatonin peaks around 9:00p.m. Ideally, this would make going to bed at 10:00p.m. and waking at 5:00 or 6:00a.m. a healthy sleep schedule. Going outside for the first time at noon will set your sleep clock for 16 hours later, or 4a.m. This makes it very difficult to fall asleep even at normal bedtime.

Some individuals, especially the elderly are ?phase advanced?. This means melatonin peaks in the late afternoon, causing sleepiness. Even if going to bed is delayed, they often wake up in the middle of the night. They usually fall asleep in the early evening and then wake up 7 hours later at 3:00-4:00 a.m. They complain of not sleeping through the night, but are actually getting plenty of sleep.

This is helped by:

? Getting late afternoon sunlight

? Melatonin (see below) intake in the morning

? Minimizing morning bright sunlight

Others, especially teens and young adults tend to be ?phase delayed?. Phase delay may be due to lack of morning bright light, lack of any exposure to outside bright light, and excessive evening artificial light. They also tend to stay up late, even when they must get up early the next morning. Their melatonin peak is delayed to midnight or later.

This is helped by:

? Getting bright morning sunlight

? Melatonin (see below) intake in the evening

? Minimizing afternoon bright sunlight

Melatonin comes in 3mg tablets.

Starting dose-1/4 tablet sublingually 3 hours before bedtime if phase delayed. If phase advanced, take in the morning.

Increase the dose to 1/2-1 if needed.

This does not help sleep associated with hyper arousal. However it can help with jet lag, shift work, or changing the internal clock.

Another option is to use an artificial full spectrum, bright light. These can be purchased by companies such as Sunbox Corp (www.sunbox.com.)

Can you sleep too much? Yes! Since after 7 1/2 hours sleep you are getting almost all REM sleep, which uses MENTAL energy, you end up more sluggish.

What?s the difference between sleep and fatigue?
Sleepiness is improved by either a nap or vigorous physical activity, fatigue is not.

People who live long, healthy lives have good sleep habits. It is like regular car maintenance. ?Pay me now, or pay me later.? You can ?make up? 6-10 hours of sleep loss, but each day after inadequate sleep you will have higher levels of stress hormones and potential detrimental affects to your health. Make the time to sleep 7 hours every night, or subject your body and brain to increased wear and tear.”

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