Rating Your Sleep Night after Night with PAP Therapy: Useful Practice or Futile Exercise?

I rate my sleep nearly every morning. Though it is mostly a mental check born of obsessive-compulsive tendencies, it nevertheless surprises me how much information I gain by taking less than a minute to clarify the good, the bad, and the ugly about my last sleep period. Usually, my shorthand approach is to give my sleep a rating on a 0 to 100% scale, but the meaning behind these percentages is what has served me repeatedly to recognize problems and their ultimate solutions. 

The two main ways in which I use my scale is to awaken and within minutes ask myself how well I slept with particular attention to the sensation of having slept deeply or not. I also think about how much dreaming occurred and whether I recall any interruptions from the night’s slumber. This information is usually so reliable I can predict beforehand to what extent my ASV PAP device will register residual breathing events or elevations of leak, both of which provide a factual basis for measuring the quality of that night’s sleep. If I feel very refreshed and recall the sense of very deep slumber combined with a memory of intense dreaming, then I expect the data on the device’s LCD to show breathing events between 0 to 0.2 and a leak in the 2 to 4 lpm or less, sometimes 0.

As you may recall from other posts, I put less stock in the duration of hours slept compared to the quality of sleep. So, the number of hours that typically shows up ranges between 6.5 and 7.5 hours, but the range infrequently may run between 5.5 and 9.0 hours. These numbers do not reflect important information unless there is an obvious disturbance that interrupted sleep. If the sleep lab calls, and I need to monitor a cardiac arrhythmia and discuss plans with the sleep tech, I recognize fewer hours slept may affect functioning the coming day. However, a night of interruptions is far less common than climbing into bed, saying my prayers and falling asleep within minutes, and then waking up in the morning without an alarm between 6.5 to 7.5 hours later and not recalling any interruptions except an occasional recall of pillow or mask repositioning, lasting no more than a few seconds of consciousness.

Despite the regularity of this schedule and the consistent high quality of sleep, a larger factor in my rating system emerges when examining what goes on during the day, particularly during the crucial window of the circadian dip (e.g. anywhere from 11 am through 4 pm or later) appears to slow things down. My observations start earlier, usually in the first hour of wakefulness where I am looking to see if clarity of thought is more prominent in my mind than the frequency of yawning. A positive “shower sign” is marked by a flurry of creative thoughts and the rapid disappearance of any struggle to awaken. Some people report showering in the morning with almost no memory traces of the experience, because it occurred in a period of burgeoning consciousness. Among those of us who sing in the shower or experience striking, creative bursts of ideas, it seems logical to assume high quality slumber from the night before. 

Such nights and related mornings indicate a rating greater than 90%, or on occasion 95%, or, rarely 100%. For any night between 90 to 100% levels, it is exquisitely clear throughout the circadian window that the inevitable dip in energy and rise in sleepiness is in fact not so inevitable after all. During the window, my energy level remains high along with my powers of concentration. On these days, my most common consumption of caffeine might be a handful of dark chocolate almonds at lunch and a cup of hot chocolate in the late afternoon as I finish up work; but sometimes, simple behavioral activation erases the need for caffeine. To be precise, the caffeine intake of chocolates plus hot cocoa probably totals between 10 to 30 mg, or roughly the range of caffeine you can imbibe with one cup of green tea.

As suggested by these examples, it is the factor of sleepiness or mental acuity or both that most reliably informs me of the accuracy of my initial rating of the night’s slumber. Sometimes, the mental acuity is so strong or clear, there can be no doubt that my percent ranking must be above 90%. On those rare days it hits 100%, no caffeine intake might occur other than the inescapable imperative to meet one’s minimum daily requirement of chocolate

Over the long-term, most nights range in the 85 to 95% levels of success. If through unusual events, sleep quality drops below 80% (or sleep was unexpectedly foreshortened as described above), then I would almost always add a dose of green tea to my daily regimen or take a short nap in the office of my CEO (who through good fortune also happens to be my wife).

How then can sleep apnea patients make use of their own rating systems on their nightly PAP therapy results? How will the rating system guide their own personal evaluations and manipulations of their sleep as well as their communications with sleep medical professionals, including physicians, sleep technologists or respiratory therapists at the DME company? 

To start, I am not suggesting you need to maintain the same level of scrutiny as in my examples. My motivation is certainly personal, but I receive the additional benefit of learning many nuances that carry over to my patients’ care. By way of example, if you are diabetic, there is a greater chance of receiving optimal care if you are able to meet at least occasionally with an endocrinologist who also is being treated for the same condition. Personal experience within individual medical professionals may make a huge difference in the degree of precision provided to you for any medical illness.

That said, some sort of rating system is worthwhile for virtually any patient except perhaps among those who report taking to PAP therapy like ducks to water. In my clinical experience, the percentage of instant success patients is usually less the one out of three and sometimes fewer than one out of ten.

The simplest rating system could include the following initial elements, singly or in combination:

  • Is an alarm clock needed for the morning awakening or can you awaken before the alarm and still feel well rested?
  • The data on your LCD every morning should read very few events, often zero, albeit tracking the data with your sleep center or DME can prove more telling if your device provides information on flow limitation events (UARS). If flow limitation is elevated, does that correlate with the way you are feeling throughout the day?
  • Leak issues should be viewed on the LCD as often as you can make time, because it is usually just a couple clicks on the device. Have you ever noticed when leak rises to a certain level, usually at or above 5 or 10 liters per minute, you experience a decline in daytime functioning?
  • Caffeine consumption is a large part of our society, but a huge bolus to start the morning and another one during the circadian window suggests compensating behavior. Tracking caffeine use is a reliable gauge of unresolved sleepiness. Have you taken the time to notice the relationship between your use of caffeine and its role as a self-medicating behavior to revitalize alertness or concentration or even poor mood?
  • Last, look at the clarity of your thinking and judgments in the first few hours of the morning. Are decisions easily made? Do work tasks or struggles seem to resolve fluidly? Do you feel you have a leg up on what’s ahead in the day? Or, do you feel behind almost from the start? 

From this point forward, additional observations are much more nuanced, because most people have developed lowered expectations about their accessible endurance to cope with either the second half of the day or evening hours prior to bedtime. Notwithstanding, as described previously in the post on normal sleepers, a notable drop off in energy will not occur after lunch or during the evening. 

In my experience, these two periods reveal a great deal about what really happened during your sleep period the night before. But, if you lower your expectations because demands at work or home drop off noticeably in terms of intensity or endurance requirements, then feeling more tired or somewhat drowsy after lunch or in the evening may not resonate with you as a problem. On the other hand, if your burden of work or chores or other responsibilities remains high throughout the day and evening as is more common in modern society, then it is worth taking a close look at how you are operating.

While behavioral activation (e.g. exercise to promote enhanced blood circulation, including a break for the gym or just basic walking around the office) or dosing yourself with another caffeine drink are very reasonable options, it behooves you to ask whether or not these signs are reflections of a reduced energy capacity due to previously misconstrued poor sleep quality.

The most subtle opportunity arises when you pay attention to many cognitive or emotional responses , but you are only likely to notice changes occurring if you are capable of honest self-evaluations.

Start with cognitive tasks. Some of the more common ones are making mistakes on the keyboard as you are typing, difficulty remembering the day of the week or the date, forgetting some piece of information that required a co-worker or a friend to jog your recall. The list is endless, but the real problem with self-observation is that everybody suffers these common mishaps from time to time and so you need to be on the alert for what might be called “deficit creep.” As people age, particularly past the age of 50, they will have the tendency to assume that mental deficits are a normal or natural part of aging. I am encouraging you to turn a skeptical eye on that age-old perspective (pun intended), because if cognition declines, then you absolutely want to go back to the drawing board and question whether or not your response to PAP is optimal. 

Daily emotional responses are also reliable, sometimes even more reliable than cognitive changes. When a person is enjoying life and feels satisfied with his or her daily energy level, he or she will usually have a much larger capacity to take things in stride. To use some old adages, they will “not cry over spilt milk” or they will say, “that’s water under the bridge.” In other words, their ability to deal with life’s unavoidable, daily frustrations will be reasonably tolerated. Now, assume PAP therapy is not delivering the highest quality of slumber. Without re-generation of a healthier energy level by way of a great night of slumber, the individual is much more likely to experience frustration in a way that triggers irritable responses, testy reactions, poorly chosen words and resultant miscommunications.

Looking at all these issues and factors, especially the final group on cognitive and emotional mishaps, may start you thinking about how well you are really doing with PAP therapy. The goal is not a perfect night of sleep, because that is going to be rare for most PAP users. But, it is possible to gain a more consistently higher quality of sleep when you are in the position to precisely rate your sleep quality night after night. Learning to do so in just a minute or so each day may lead you to a much clearer sense in making adjustments to your PAP device or discussing related adjustments with your sleep medical providers. So, if you like, establish a rating system that suits your lifestyle and see what you learn.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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