Sleep Dynamic Therapy

Archive for September, 2008

A very interesting post over at Ask Dr. Helen via Instapundit…

And my comment about the same:

Helen,

I’ve queried many of my patients through the years on this issue, and the most parsimonious explanation for the decision to sleep apart is reflected in your comment about sleep difficulties such as RLS, snoring, and especially sleep-disordered breathing, such as sleep apnea or upper airway resistance syndrome. However, I think this point can be taken deeper, because while some people are aware of their reasons for sleeping apart, that is, they know they sleep better, a sizeable proportion of people invoke secondary explanations and don’t realize they are actually suffering from an underlying sleep disorder. Instead, they just develop the mindset of wanting to sleep alone and think that’s the full rationale.

The clinical pearl here is that if the person says “I sleep better when I sleep in a separate bed,” what they are often meaning is that they suffer from some form of an intrinsic sleep problem that makes them at risk for more awakenings, arousals or other degrees of sleep fragmentation when they are exposed to the additional “variable” of another person in the same bed.

Many people who sleep separately will reject this perspective, because they imagine nothing is fundamentally wrong with their sleep and that the other person in bed is simply causing the problem.

But, here’s the conundrum that delays most poor sleepers from figuring out that they are a poor sleeper: all sleep patients can’t really know how they are sleeping because they are asleep at the time!

So, the more common direction of this relationship is that many people suffer from subtle disturbances in sleep quality that create the opportunity for worse sleep quality when exposed to an antagonistic stimuli. One of the most frequent inciting factors is another body in the bed, which creates more heat, which then worsens breathing, because sleep breathing is improved in a cooler environment compared to a warmer one. So with that little fact, we would predict that many individuals who sleep better in a separate bed actually suffer some form of a sleep breathing problem.

The interesting thing about these facts are that a truly normal sleeper carries none of the risk described above because their sleep quality is well consolidated, and therefore it would require a more invasive stimuli, like dogs barking inside the house, to actually interrupt sleep. Another body next to a truly normal sleeper would in most cases have very little impact on the normal sleeper.

Something to sleep on

Barry

“Government efficiency” is surely an oxymoron, but think again, because the government is extremely efficient in wasting your tax dollars. Last week at the sleep lab, we conducted a repeat diagnostic sleep study in a Medicare patient (reimbursement ~ $800), which we believe was a complete waste of time and resources. Why did we have to repeat this study?

Because in the patient’s earlier split night study, in which this individual suffered from raging and life-threatening sleep apnea, the patient could only sleep for 87 minutes before we needed to switch over to PAP therapy, after having witnessed more than 100 apneas as well as repetitive oxygen desaturations below 60%.

The DME company claimed that Medicare would not cover the cost of the patient’s PAP device, because the individual needed 120 minutes of sleep to confirm the diagnosis of…did I mention it was raging life-threatening sleep apnea…

So, in the infinite wisdom of Medicare, an institution that imagines that sleep doctors don’t actually know what’s best for their patients, we were obliged to have the patient spend another night in the lab to confirm the diagnosis, because on the first night (split-night) we made the egregious mistake of being overly concerned with treating our patient for a serious medical condition and having enough time to complete a superior titration.

There ought to be a law!