Ask the Doctor: April 2008

Question: Hi Dr. Lockwood. I am a 60 yr old female who is suffering from insomnia. Last year I visited a holistic physician who said that my Vitamin D reading was 14.5 but told me to take a good multi-vitamin. I have been taking two tablespoons of Cod Liver Oil daily. He is now giving me an intravenous feeding 6 times of Cortisol and B vitamins but I am not seeing much of a change. Can a Vitamin D deficiency cause a sleeping problem? I feel anxious and now worry about not sleeping so I am in a vicious cycle. I’m emotional because I’m tired. Ambien made me very groggy during the day. Benadryl doesn’t help. I would appreciate your thoughts on this. This has been going on for the last five years on and off but now it is severe. I’m not having hot flashes. Thank you for your input. – K.M.

Answer:Your question has multiple issues and I will try and address them all. First, if your vitamin D level is 14, it is well below the level of 32 that I try to get my patients to. You need more aggressive supplementation. Even well-known multivitamins don’t have enough to replace your level back to normal. Centrum Silver has 500 IU per tablet and One-a-Day Women 50-plus has 800 IU. Single tablet vitamin D supplements have about 1000 IU in each one. In order to get your level up to 32 you really should be more aggressive. If you take two over-the-counter supplements plus your vitamin you will probably get your levels back to normal soon. I still recommend the higher doses of 50,000 IU weekly for 8 weeks and then monthly. The 50,000 IU tablet is a little harder to find, however.

It is quite possible that the vitamin D level is affecting your sleep pattern because it does affect mood as well as anxiety. However, there is no direct link between insomnia and vitamin D deficiency to my knowledge. Many other aspects of your health are affected by vitamin D, you can only benefit from getting your level back to normal.

I am concerned about the IV treatments of cortisol and vitamin B that you are getting. If you are not getting better with treatment, I would stop both of the treatments. You should be getting adequate vitamin B levels from your multivitamin and your diet. Any of the B vitamins your body doesn’t use, you will filter them out through your kidneys, thus giving you very expensive urine if you have been getting high doses through the IV treatments.

My biggest concern for your health is the IV cortisol. If you are clinically deficient in cortisol, you should be seeing an endocrinologist because there may be other hormones you are deficient in that are made by the adrenal glands. If you are not clinically deficient and he is using the IV cortisol for other reasons, you are putting yourself at risk for side effects of having too much cortisol in your body, including osteoporosis. Excess cortisol increases the rate of bone loss. Increased cortisol can also raise your blood sugar and lead to diabetes, which sometimes resolves when the cortisol is stopped, but not always.

As for your insomnia, there are a couple of things that you can do to help break the cycle. It definitely gets harder to sleep if your insomnia is persistent because of the anxiety you mentioned and the fear of not being able to fall asleep.

The first thing you need is good sleep hygiene. This means no naps during the day so you are tired at night. Do not go to bed until you are completely tired, so if you need to read or watch TV, do it in another room so the brain is not confused about the purpose of the bedroom. The bedroom is only for sleeping and sex, so no eating, reading or watching TV in there if you are having trouble sleeping.

A warm bath or shower before bed may help you to relax. Meditation techniques can help you to relax when you are in bed, also. Try counting slowly backwards from 10. Count once for each breath in and out, make sure you fill up your lungs completely and exhale completely. While you are breathing, concentrate on relaxing each body part, starting with your toes and working your way up. This will help the anxiety component.

Another option is melatonin, which is an over the counter supplement. Melatonin is a substance produced naturally by your brain in response to lower levels of light, which is how your body tells when it is night. The over the counter supplement can help increase these levels. There are two prescription medications you might want to ask your doctor about, as they work differently than Ambien. Rozerem is a newer drug that increases melatonin levels in the brain (much like the supplement, only it is FDA approved). Rozerem takes a little time to kick in, so you have to be patient. The other drug that may help is Trazadone. Trazadone is an older antidepressant that can cause you to be sleepy. The insomnia dose is much lower then the dose used for depression and when taken at night, can really help. I have recently had good responses in my patients to Trazadone.

I hope you are able to resolve some of these problems you are experiencing.

Dr. Karen Lockwood is a graduate of University of Oklahoma College of Medicine. She completed her residency in Internal Medicine at Henry Ford Hospital in Detroit. She is board-certified in Internal Medicine and is currently in private practice in Troy, MI.

If you would like to submit a medical question to Dr. Lockwood, Please email your question to askthedoc@healthandleisureonline.com.

*Advice found within this article is for informational purposes only and should not replace the advice or recommendations of your physician.

Are You Suffering From Sleepless Nights?

With Gary Trock, MD

There are many different types of disorders that affect sleep, but the two most common are sleep apnea and insomnia. The two conditions are different in many ways but can both have negative effects on our bodies, minds and overall health.

INSOMNIA

According to Gary Trock, M.D, of Beaumont Hospital, approximately 30-50% of people will suffer from acute insomnia, while 10% of the population suffers from chronic insomnia; defined as lasting three months or longer.

“Insomnia is when you have difficulty falling asleep, staying asleep, waking up too early or when you do not get non-restorative sleep,” says Dr. Trock. “Most times it is temporary due to stress levels or other factors, but a stressful event may cause the insomnia that changes ones habits or behaviors and leads to chronic insomnia.”

Chronic insomnia is generally a psychophysiologic insomnia and may be caused by a variety of factors including mental illness, substance abuse, chemical imbalance or changes in lifestyle. Many people with mood disorders also have a preexisting sleep condition.

TREATMENT OF INSOMNIA

There are many prescription medications available to help manage insomnia, but they generally help a person fall asleep or maintain sleep through the night. However, for more severe conditions you may need treatment at a sleep disorder clinic.

One way to begin understanding your sleep patterns is to maintain a sleep diary, says Dr. Trock. This will allow you and your physician to better understand how much sleep you are getting, when you are falling asleep or waking, and what some of the circumstances around you may be contributing to your insomnia.

One form of treatment is called Sleep Restriction Therapy. Dr. Trock explains that this entails making the patient get out of bed as soon as they wake. For example, if a patient lies in bed for nine hours but only sleeps for five hours, you make the patient get out of bed at the end of the five hours regardless of the time of the day or night.

Other non-medicinal therapies include Stimulus Control Therapy and Paradoxical Intention Therapy, says Dr. Trock. Each can help you manage your insomnia. With Paradoxical Intention Therapy you tell yourself you are going to do the opposite of your intention. For example, “I am not going to fall asleep.”

With Stimulus Control Therapy, you don’t stay in bed any longer than 20 minutes without falling asleep. If you are still awake, you get out of bed and read a book, watch television, work on the computer or other project until you become tired again.

Another mistake people make with insomnia is doing other activities in bed other than sleep. “The bed is for sleep and sex, no televisions, stereos, computers,” warns Dr. Trock.

SLEEP APNEA

This condition receives a lot of attention because of the physicality of the condition. Sleep apnea occurs when your sleep is interrupted by pauses in your breathing. This leads to an interrupted sleep pattern which causes the patient to feel tired or fatigued during the day. According to the National Institute of Health, the interruption in breathing can last 10-20 seconds, and occur 20-30 times in a night.

Snoring is one of the symptoms and obesity is one of the risk factors for sleep apnea. Generally, the spouse or loved one identifies the problem because of the snoring, says Dr. Trock.

“Snoring is a symptom for most, but not all. Bed partners hear the snoring, but the patient can experience sudden awakening, shortness of breath with their heart pounding, and dreaming that you are suffocating or drowning,” says Dr. Trock. “Other symptoms include decrease performance at home, work or school, in ability to concentrate and falling asleep during the day. Another medical symptom is high blood pressure that doesn’t respond to medication.”

With the lack of oxygen in the blood due to the pauses in breathing, a patient can suffer immediate dangers such as cardiac arrest or run the risk of stroke.

Dr. Trock says that diagnosis requires a sleep study to determine the severity of the apnea. The patient is often prescribed CPAP (Continuous Positive Airway Pressure) to help correct the problem once the diagnosis is made. CPAP is the most common, long term treatment option for patients with moderate to severe sleep apnea. It is a process of forcing oxygen into the lungs and prevents apneas from occurring. Because it is a recognized treatment, the CPAP machine is covered by insurance.

Surgery is also an option reserved for mild to moderate cases, says Dr. Trock. However, it is an option most often reserved for patients who cannot tolerate CPAP, or if there are other physical blockages causing sleep apnea.

If you suspect you may have sleep apnea it is important to see a sleep specialist to get the proper diagnosis, says Dr. Trock. To improve your sleep, it is important to recognize symptoms of problematic patterns. For sleep apnea, obesity is a definite risk factor, says Dr. Trock. Weight loss can be an effective way to relieve the severity of your apnea.

It is also important to recognize how much sleep your body needs. This can vary depending on your age and health habits. “Sleep patterns can change over time. You can condition yourself on how much sleep you need,” says Dr. Trock. “There are short sleepers or long sleepers that function well as long as they get their designated amount of sleep. This could be 4-5 hours for short sleepers and 10-12 hours for long.”

It is important to recognize the signs and symptoms of sleep problems and address them with your physician. This is mostly due to the other health problems that can occur as a result of sleep deprivation.

So the next time you think you are a little sleepy, pay attention to how often you feel that way. You may be suffering from a sleep disorder.

Gary Trock, M.D., is board certified in pediatrics, neurology, clinical neurophysiology and sleep disorders. He received his medical degree from the University of Michigan and completed his Residency in pediatrics at the University of Minnesota followed by Fellowships in Adult and Child Neurology and Clinical Neurophysiology. His Fellowship in Sleep Medicine is from Georgia Tech. He has been at Beaumont since 1980.