Sleep Medicine and Disorders

There is no reliable estimate of how many Ambien users sleepwalk, and no one knows who might be at risk. The prescribing information for Ambien lists somnambulism as a "rare side" effect, meaning that it has been reported in fewer than one in 1,000 patients. (Photo Illustration By Bill O'Leary - The Washington Post)

Michael Sateia, chief of the Section of Sleep Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was online Tuesday, March 14, at 1 p.m. ET to field questions and comments about sleep disorders and the reported possible side effects of Ambien, the most prescribed sleep medication in the United states.

From The Post:

To Sleep, Perchance to . . . Walk (Post, March 14)

Ambien and Sleepwalking Risk (Post, March 14)

The Transcript follows.

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Michael Sateia: Hi - and welcome

First, a general comment. Medical problems, including sleep disorders, are often complex and it is, of course, impossible to capture the details adequately in a short question and answer. So, rather than responding to a specific writer's circumstance, I will choose to respond to the general issues raised by the questions. I think that is going to be the most helpful for all.

MS

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Dayton, Ohio: Hi! I've suffered from sleep disorders for some time. It's gotten to the point where I obsess about them all the time. I can't pinpoint the exact cause - caffeine, alcohol, room temp, room noise or light, mattress comfort, work stress, food before bed, etc. Even when conditions are "perfect" I still get only about four hours of sleep before I enter a cycle of one hour sleep and wake up and sleep for an hour and wake up for the rest of the night. Any suggestions on how I can get a better night's rest? Thanks!

Michael Sateia: You raise some very important issues in your question. It's important to remember that sleep disturbances such as insomnia are often the result of many different factors. First, we want to make sure that there are not unrecognized problems such as depression, other psychiatric disorders, medications, schedule problems, medical illnesses, or other primary sleep disorders such as breathing or movement disorders that may be contributing to the insomnia problem. Once these problems have been addressed, to the extent necessary, we look at additional factors that develop during the course of insomnia and tend to create a vicious cycle. These are things such as:

* worry about not sleeping ("obsessing")and negative expectations

* staying in bed for long hours awake (which worsens sleep because the bed becomes associated with waking and frustration)

* rearranging schedules in a manner that is not conducive to normal sleep (e.g. "sleeping in" to make up for lost time at night)

These and other associated factors (e.g. needing to have everything "perfect" in order to sleep), are often most effectively addressed through what is called cognitive-behavioral treatment for insomnia. This is usually a several visit, straightforward process that helps people to unlearn damaging sleep habits and restore healthier sleep.

Also, keep in mind that you should discuss this with your primary care doctor and, if necessary, consider referral to a sleep specialist for further assessment and ideas about getting help.

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Fairfax, Va.: I make sure I give myself 8 hours or more of sleep time when I taking Ambien but when I drive to work in the morning I sometimes need to pull over and close my eyes because I'm falling asleep behind the wheel. Why does it make me so tried when I do give myself the sleep time recommended for this medication?

Michael Sateia: Well, first I'd like to say that drowsy driving is a significant public health issue. When one is less than fully alert behind the wheel, it is essential to get off the highway - as you do.

Medications certainly have different effects on different people (depending on age, other meds taken, individual physiology and the like. So the duration of clinical action may vary. If morning drowsiness or "hangover" is a problem, it should be taken up with the prescribing physician. One of the important principles in prescribing sleeping medication is to find one that has the correct duration of action for a given person - long enough to address the sleep problem but not so long that it cause daytime adverse effects. Dosage or timing adjustments or a switch in medication may be appropriate when problems of this nature occur.

One other thought is that when daytime sleepiness occurs, it is not always related to medication a person is taking. There are many causes of sleepiness - insufficient sleep, disturbance in sleep quality such as we see in sleep apnea or other conditions, medical problems and so forth. So people should keep an open mind and not always assume that the medication is to blame.

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Hanover, N.H.: I'm curious about the sleepwalking/sleep eating side effects of Ambien. Both my husband & I take Ambien (he has 10mg and I have 5mg) and we have also both experienced those side effects w/out knowing why. He has often had problems with sleep eating and although I have experienced some short term memory problems it's only recently that I had a problem with sleep walking. Should we be investigating some other sleep prescription? (He has also tried Lucent and Sonata.)Thank you

Michael Sateia: I think that it is important that we put the sleepwalking/eating reports regarding Ambien into some context. Clearly, this is a problem that has occurred for a significant number of people. However, until we have more data, we do not really know how widespread this is. In addition, we do not know the extent to which this issue is specific to Ambien. Certainly, in the past, there have been concerns raised regarding behavioral disturbances associated with other sleep medications. And finally, we need to understand more about the circumstances under which such episodes occur - does this have to do with timing of the medication? Age of the consumer? Other medications or substances, such as alcohol, that are used concurrently, the nature of the sleep problem or other associated conditions.

That said, when behavioral problems are occurring, they should be taken up with the prescribing physician. Are there co-existing sleep disorders that may be fueling this (e.g. we see sleepwalking behaviors in a fair number of our sleep apnea patients)? Safety measures are always important - that is, taking efforts to ensure that a sleepwalker will not come to harm - or potentially harm others. And certainly, consideration of alternative medications would be appropriate if problems with a given medication persist.

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White River Junction, Vt.: What are the differences between these newer drugs (Ambien, lunesta, etc.) compared to the older benzodiazapines? Why not just use the older ones which don't have the sleep walking side effects as commonly and have been tested for years?

Michael Sateia: There are some important differences between the newer type sleeping medications (or hypnotics)and the older "benzodiazepine (BZD)" group. All of these meds work at the so-called BZD receptors in the brain. The newer ones, however, have a more specific action that is probably "cleaner" in the sense that its action is focused particularly on the receptors felt to be responsible for sleep-inducing effects. In the past, there have been many concerns (though little data) generated regarding long-term use of the older BZD group - and these drugs were not approved for long-term use. Now, one of the newer agents (eszopiclone or Lunesta) has been studied for 6 months in a controlled study and found to maintain effectiveness while producing relatively few adverse effects or safety problems. The sense is that other newer agents will follow suit in that respect.

So, while the older - and definitely less expensive - BZD group undoubtedly works well for many people now using them, we are seeing a gradual shift toward the newer compounds for these reasons. And, again, it is worth keeping in mind that the BZD group is not FDA approved for long-term usage - and that management of chronic insomnia problems should include more than just medication.

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Olney, Md.: I rarely sleep over 5 hours a night and occasionally get by on 3 hours. Falling asleep has never been a problem, but I consistently wake up after 4-5 hours of sleep. Occasionally I feel tired during the day, but mostly feel awake and am function normally. If possible, I usually take a 1 or 2 hour nap on the weekends to catch up. I have never resorted to sleeping aides and hopefully will never have to depend on any. Do I have a sleeping disorder or am I simply a person that can get by on less sleep?

Thank you for responding.

Michael Sateia: There is certainly variability with respect to the amount of sleep that people require. While the majority probably need somewhere in the range of 7.5-8 hours (but often choose to get much less), there are some who need substantially less. The main measure of sleep need is daytime function. To the extent that one is fully alert, high functioning and apparently without consequences from less than 7-8 hours a night, there may be a normally reduced physiological need for sleep.

However, a cautionary note is that for every so-called "short-sleeper" out there, there are probably many more who are getting by on less sleep but paying some price. For someone unable to get more than 4-5 hours/night, it is probably worth considering whether there might be an insomnia problem. The place to start would be talking with a primary care doctor and considering if further evaluation by a specialist is in order.

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McLean, Va.: This a question about sleep apnea. My partner is in excellent health, does not snore, and is not aware of any sleep problems. However, I am sometimes aware, when listening to her breathe during the night, of a pattern that concerns me: 10 or 12 normal breaths followed by a pause of as much as 6 or 8 seconds, followed by a strong exhalation. This pattern can continue for quite a long period of time. Does this sound like it falls within the definition of sleep apnea? If it does -- is it something that should be addressed? If it should -- how does one find a sleep specialist?

Michael Sateia: The diagnosis of sleep apnea is based on careful evaluation of multiple issues. There are two types of apnea - obstructive sleep apnea - by far the most common and generally what we mean when we say "sleep apnea" - and central sleep apnea - which occurs as a result of the brain not sending the signal to breathe.

Obstructive apnea is almost always associated with snoring. While the absence of snoring does not preclude the possibility, it makes it far less likely. The other major symptom that we look for in obstructive apnea is daytime sleepiness - drowsiness or involuntary dozing when one is in quiet, sedentary situations.

Brief (6-8 seconds) pauses in breathing may be physiological (i.e. normal), particularly in certain stages of sleep.

Depending on other medical issues, there may or may not be reason for concern and when concerns arise, there's no harm in running it by your doctor.

You can locate an accredited sleep disorders center from the American Academy of Sleep Medicine web site - www.aasmnet.org. A complete listing is available.

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Ground East, White River Junction, Vt.: Given the proven benefits from cognitive-behavioral treatments for insomnia, and the large number of people who suffer sleep disorders, why are we not seeing greater efforts from both doctors and managed care providers to make these treatments more readily available? And... How do the two treatments compare?

Michael Sateia: Thanks for the question. What we know is that cognitive-behavioral treatments for insomnia (CBT-I) produce significant improvement which are durable. This is in contrast to short-term courses of sleep medications, which produce short-term improvements that do not seem to last.

Currently, a task force from the American Academy of Sleep Medicine (which I chair) is actively engaged in addressing what you correctly define as a critical need for greater availability of CBT-I, through development of widespread training programs. we have a ways to go with this, but the work has begun.

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Michael Sateia: All-

Thank you for your many great questions. I realize that I have left most unanswered but must move on to seeing patients. Perhaps another time. Sleep well!

MS

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