Which treatment may increase restlessness and insomnia in a patient with COPD

Researchers from St. Michael’s Hospital in Toronto have found that a popular class of drugs commonly used to treat sleep and mood symptoms continues to be frequently prescribed despite being known to have potentially life-threatening side effects.

Previous studies have linked benzodiazepines – a medication class that may be used in chronic obstructive pulmonary disease (COPD) to treat symptoms of insomnia, depression, anxiety and shortness of breath – with adverse outcomes. Until now there has been little information on how frequently it’s prescribed or who is using it.

“I see a large number of COPD patients taking this medication class to help relieve disease-related symptoms like insomnia, depression and anxiety,” said Dr. Vozoris, lead author and respirologist at St. Michael’s. “But considering the potential respiratory side-effects, and the well-documented neurocognitive side effects like memory loss, decreased alertness, falls and increased risk of motor vehicle accidents, the high frequency of benzodiazepine use in COPD is very concerning.”

COPD, also known as emphysema or chronic bronchitis, is most commonly caused by smoking in North America. American Thoracic Society-European Respiratory Society guidelines recommend that benzodiazepines be avoided in these patients because of potential respiratory-related side-effects.

The study, published online ahead of print in Drugs and Aging, looked at more than 100,000 adults 66 years and older with COPD in Ontario between 2004 and 2009 to see how many new benzodiazepines were dispensed and the severity of each patients’ COPD while on the drug.

The results found that new benzodiazepine dispensing was common and occurred in more than a third of the adults. Use of the drugs was 40 percent more common amongst those with more severe COPD. This group also had the highest number of repeat prescriptions and early refills and benzodiazepines were also commonly dispensed to patients while they were having flare-ups of the disease.

“These findings are new and they are concerning because they tell us that the patients most at risk to be affected by the adverse effects of this drug are the same ones that are using it with the most frequency,” Dr. Vozoris said. “This medication could be causing harm in this already respiratory-vulnerable population.”

Although benzodiazepines can be effective for helping patients sleep, this medication class has been previously found to affect breathing ability and oxygen levels at night.

“Patients need to hear this and health care providers need to give thought into who they are prescribing this medication class to,” Dr. Vozoris said. “We’re talking about a very vulnerable sub-group and we may be inappropriately prescribing this medication class to those patients.”

Clinical guidelines from the American Academy of Sleep Medicine recommend that sedative hypnotic drugs or benzodiazepines should be supplemented with behavioral and cognitive therapies, that the lowest effective dose should be prescribed and that medication should be tapered when conditions allow.

If you have chronic obstructive pulmonary disease (COPD), and you feel exhausted or drowsy in the morning, you’re not alone. As many as 70% of patients with chronic obstructive pulmonary disease, or COPD, have symptoms of fatigue in addition to respiratory issues. Often this fatigue is caused or made worse by poor sleep quality and breathing problems during the night. How does trouble sleeping affect your COPD?

Long-term fatigue can negatively impact your life, causing poor concentration, frustration and even depression. If you already have depression, anxiety or other mental health issues, lack of sleep can set off a harmful cycle, making you feel worse as time goes on. Taking steps to help your sleep patterns can boost your energy and may also improve your COPD symptoms.

Why COPD Affects Your Sleep

If you have COPD, your lungs don’t work the way they should. This means it’s harder for your body to get the oxygen it needs and remove carbon dioxide, causing symptoms such as coughing, wheezing and shortness of breath. If you’re sleeping—or trying to sleep—the muscles in your lungs and elsewhere in your body relax and your respiratory drive goes down. For a normal person, this isn’t a problem, but for a person with COPD, it can cause several problems, including low oxygen saturation and high carbon dioxide levels during your sleep, which can also affect your daytime symptoms, including:

• Acid reflux can cause heartburn and make your coughing worse.
• Insomnia is a condition where you wake up and can’t fall back asleep. Insomnia may be caused by coughing, COPD medications, mental health issues or a combination of factors.
• Lack of oxygen in your blood, a condition also known as hypoxemia, can lead to pulmonary hypertension, or high blood pressure.
• Obstructive sleep apnea causes you to stop breathing briefly during your sleep. It’s often indicated by heavy snoring or chronic fatigue. Having OSA in addition to COPD significantly worsens overall COPD outcome.
• Restless leg syndrome, a nerve disorder that causes your legs to move uncontrollably, can also cause pain.
• Too much carbon dioxide in your blood, also known as hypercapnia, is often indicated by headaches in the morning when you wake up and can cause worse breathing symptoms during the daytime.

Often these problems become worse during the REM sleep cycle, which is the shallower type of sleep when you experience dreams.

Improve Your Sleep Hygiene

A healthy sleep routine may make it easier to fall asleep and get better quality sleep. Start with the following tips:

• Go to bed and get up at the same time every day. Regulating your body clock may be hard in the short term, but your consistency can pay off with more restful sleep.
• Limit alcohol, caffeine and nicotine. All three drugs will disturb your sleep patterns, making you more likely to feel tired in the morning. Additionally, smoking can make your COPD symptoms worse.
• Relax before bed. At least an hour before your scheduled bedtime, turn off your electronic devices, including the television, and start preparing your mind for bed. You could use this time for a warm bath, meditation, a cup of calming herbal tea or a good book.
• Skip the naps. Too many naps during the day—especially if they last more than 30 minutes—can disrupt your nighttime sleep.
• Try daily exercise. If you’re physically able to do so, getting your body moving every day is a great way to help you sleep better every night. Just don’t work out too close to bedtime, which can keep you awake.

Watch a Video on Better Sleep

Assess Your Bedroom

Another important part of your sleep hygiene is making sure your bedroom is designed for sleep. To make a big impact on how well you sleep, ask yourself a few simple questions:

• How’s your bed? Is your mattress old and sagging, or does it provide the right amount of support? What about your pillows? Sleeping in an elevated position, like on a wedge, may help you breathe in more oxygen and can also reduce symptoms of acid reflux.
• Is your bedroom just used for sleep? Do you use your bedroom as a second living room to watch TV or a home office to work on the computer? This may make it harder for your mind to associate the room with sleep, which can cause problems with falling asleep.
• How is the light situation? Exposure to morning light helps keep your body clock on schedule and makes you feel less tired during the day. Make sure your window coverings allow some light in as the sun rises. If you sleep during the day due to your work schedule, try blackout curtains and an alarm clock that slowly lights up to mimic dawn.

Talk to a Medical Expert About Your COPD and Sleep

If DIY sleep hacks haven’t improved your symptoms and you are still feeling tired throughout the day, a University of Maryland Medical System sleep professional can help. We have physicians that specialize in COPD and sleep problems, including hypoventilation. Options that could improve your sleep might include:

• Adjusting your medications or the times of day at which you take them
• Cognitive behavioral therapy to treat insomnia or other underlying mental health issues
• Continuous positive airway pressure therapy to help sleep apnea
• Hybrid nighttime ventilators to improve your lung function while sleeping, especially in those with severe COPD
• Learning breathing techniques that can improve shortness of breath and help with relaxation
• Losing weight
• Oxygen therapy to improve your nighttime oxygen intake
• Quitting smoking
• Sleep disorder studies to better assess what is happening when you sleep or to diagnose other possible underlying conditions
• Treatment for acid reflux, allergies, congestion or other issues

Sleeping pills tend not to be a good option for people with COPD. In addition to the possible risk of addiction to some medications, many sleeping pills further depress your respiratory system, which can be dangerous.

Listen to a Podcast about Sleeping Better

Do you have trouble falling asleep or wake up feeling just as tired as when you went to bed? You are not alone! But don’t fear, Dr. Emerson Wickwire, a sleep specialist at UMMC Midtown Campus, is here with tips on how to get better sleep, and when to know if you should see a specialist to get some rest. Listen to the podcast.

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