Advocate for Self-care and Treatment for Sleep Challenges– By Keith Torkelson MS, BS

 

Ability to Communicate

The ability to communicate is the skill of effectively sharing and understanding information, involving clear speaking, writing, and nonverbal cues (body language, tone) and essential active listening, empathy, and adapting to different situations to convey messages and build connections, crucial for personal and professional success. It's a two-way street of both sending clear signals and accurately interpreting others' messages, focusing on clarity, conciseness, and understanding emotions and intent.

 

##	Factor (A-Z)	2025 0521 W-RT SW-JB	2025 0708 TU-RT SW-JB
01	No Alcohol Abuse / Use	1.00	1.00
02	Ambien Benefits (*)	1.00	1.00
03	Little Anxiety	0.50	0.75
04	Ativan Security	0.75	0.75
05	Clozapine Efficacy	1.00	1.00
06	Little Confusion	0.75	0.75
07	Little Dependency	1.00	0.25
08	Little Depression	0.75	1.00
09	Good Concentration	0.60	0.75
10	Appropriate Drowsiness	1.00	1.00
11	No Genetic Mutation related to GABA chemistry (Suspected)	0.50	0.50
12	Managed Insomnia	1.00	1.00
13	Not Irritable	0.75	1.00
14	Few Problems	0.75	0.75
15	Minor Mood Swings	0.75	0.75
16	No Muscle Spasms	0.90	1.00
17	No Panic Attacks	0.90	0.90
18	Short Periods of Stress	1.00	1.00
19	Appropriate Sleepers (**)	1.00	1.00
20	Temporary Stress	1.00	1.00
21	No Tolerance	0.90	0.90
22	No Tremors	0.75	0.75
	CALC	=18.55/22	=18.80/22
	Sleep Associated Strengths Score 22 Items (HSF) =	84.3%	85.5%

(*) – Doctor re-evaluates each appointment

(**) – Alternatives to Ambien

Advocate

>Buster’s niece is his overall advocate and power of attorney.

Last Reviewed: 20260125-SU

FAQ - What is wrong with my brain chemistry?

 

Typical Neurotransmitter Levels in Blood

Typical neurotransmitter levels in blood vary widely, and these levels are not typically used as a primary diagnostic tool for mental health conditions. While neurotransmitters are crucial for brain function, measuring their levels in blood doesn't always reflect their activity in the brain, where they primarily act. Blood levels can be influenced by various factors, including medications, diet, and even physical activity.

 

How is it a Sleep Disorder?

A sleep disorder is a condition that disrupts normal sleep patterns, affecting the quality, timing, and amount of sleep, which leads to daytime distress and impaired functioning. It is identified by chronic issues like taking >30 minutes to fall asleep, frequent waking, loud snoring/gasping, or excessive daytime sleepiness.

 

Practical - Things to Look Up

• Short Term Fixes
• Ambien
• Cognitive Behavioral Therapy
• Diphenhydramine (Benadryl)
• Lemborexant (Dayvigo)
• Lorazepam
• Melatonin
• Restoril
• Trazadone

 

Long Term Fixes

• Adenosine
• Chamomile Tea
• Clozapine
• GABA
• Limit Caffeine
• Limit consumption of alcohol

 

Solution

 

Goals

Sleep all night

Peace and pleasure during the day

Contentment

 

FYI - Diphenhydramine

Diphenhydramine (commonly Benadryl) is a first-generation antihistamine used to treat allergy symptoms (sneezing, itching, hives), the common cold, insomnia, and motion sickness. It works by blocking H1 receptors (reducing histamine) and acting as an anticholinergic. Common side effects include drowsiness, dizziness, and dry mouth. Available in oral, topical, and injectable forms, it should be used cautiously due to potential for sedation and, in overdose, serious heart issues.

 

Alternatives to Ambien

Alternatives to Ambien (zolpidem) for insomnia include prescription drugs like eszopiclone (Lunesta), trazodone, and dual orexin receptor antagonists (Belsomra, Dayvigo). Over-the-counter (OTC) options include melatonin, diphenhydramine (Benadryl), and doxylamine (Unisom). Non-pharmacological approaches like Cognitive Behavioral Therapy for Insomnia (CBT-i) are highly effective alternatives.

 

Housing Position

>Current living situation at Harvest is good enough.  If medication, peace or sleeping goes wrong these would be conditions for relocation.  Our current treatment plan is working yet the doctor indications he wants to stop our Ambien.

 

Team Work

Consumers are becoming more knowledgeable about medications, but professional expertise remains valuable. A combination of consumer research, clear communication from healthcare professionals, and ongoing education efforts is needed to empower individuals to make informed choices about their medications.

 

Medication Position – Shared Decision Making

^>The doctor knows more about our case and what we need.  However, it's equally important to remember that shared decision-making is a crucial aspect of modern healthcare. Based on lived experience and a college education we know our case and needs better than anyone.  Individuals, leveraging their lived experience and educational background, often possess unique insights into their specific circumstances and needs.

 

Sleep

Null Hypothesis - We do not lack the endogenous chemistry to sleep.

Hypothesis – We lack the endogenous chemistry to sleep.

 

FYI - Clinical Chemistry of Sleep - Brain Basics: Understanding Sleep

National Institute of Neurological Disorders and Stroke (.gov)

https://www.ninds.nih.gov/health-information/public-education/brain-basics/brain-basics-understanding-sleep

Feb 25, 2025

Two internal biological mechanisms—circadian rhythm and homeostasis—work together to regulate when you are awake and when you are asleep.

 

Problems with GABA – Risk Factors

^>Due to intense sleep deprivation and interruption Buster appears to lack the natural chemistry for sleep.  Most likely gamma-aminobutyric acid (GABA) is involved.  Ambien is a short term solution yet the doctor is considering taking Buster off Ambien.  Ambien has proven itself over the course of 1-2 years and is something that is effective and well tolerated.  “Long-term reliance on chemical sleep aids, whether prescription or over-the-counter, is generally not recommended due to potential side effects and risks. While some chemicals like melatonin, GABA, and adenosine play a natural role in sleep regulation, excessive or prolonged use of synthetic versions can interfere with the body's natural sleep-wake cycle and lead to complications.”  Without medication Buster has an abnormal sleep-wake cycle.  Before taking him off his “sleeper” we need to come up with something to replace it.  For Buster Ambien is augmented with Lorazepam and CloZAPine.  Without these three medications Buster doesn’t sleep.  Without sufficient sleep his risk factors increase.  As a coping measure for increased risk factors he has a history of calling 911 and ending up in the hospital.  Presently, if Buster were faced with prolonged sleep deprivation (more than 72 hours) he would prefer Medical Assistance in Dying (MAiD).

 

Cost-Benefit

^>Costs are what you give up or spend, while benefits are what you gain or receive from a decision or action. Cost-benefit analysis is a method of evaluating these, often using monetary units, to determine if the benefits outweigh the costs.  In a nutshell, the cost of giving up one of Buster’s sleep associated medication exceeds the benefits.

 

Example Restoril Substitute

Restoril (Temazepam) is a medication used to treat insomnia, helping individuals fall asleep and stay asleep. It's a benzodiazepine that works by slowing down brain activity, but it comes with potential risks like dependence, misuse, and side effects. The cost of Restoril can vary depending on factors like insurance, pharmacy, and dosage.

 

Benefits of Restoril

The key benefits of Restoril for treating short-term insomnia include…

Improved sleep onset

It can help individuals fall asleep faster.

Reduced nighttime awakenings

It can help individuals stay asleep longer by reducing the number of times they wake up during the night.

Enhanced sleep quality

By promoting longer and more continuous sleep, Restoril contributes to a more restorative sleep experience.

Minimal disruption to sleep structure

Unlike older hypnotics, Restoril doesn't significantly disrupt the natural stages of sleep like REM sleep, which is important for brain recovery.

 

Will a Sleep Disorder get Better with Age?

No, sleep disorders generally do not get better with age and may, in fact, become more common. While the need for sleep remains relatively stable throughout adulthood, the ability to achieve restful sleep can decline with age. Many older adults experience difficulty falling and staying asleep, leading to increased nighttime awakenings and reduced deep sleep.

 

Settings

“Hospitalization typically incurs higher costs than the use of benzodiazepines alone, but offers the benefit of a more controlled environment and access to medical professionals for monitoring and treatment. Benzodiazepines can be cost-effective for certain conditions like anxiety or insomnia, but can also lead to adverse events, including falls and accidents.”

 

Are BZDs part of palliative care?

Yes, benzodiazepines (BZDs) are a common and important component of palliative care, frequently used to manage symptoms like severe anxiety, breathlessness, agitation, and terminal restlessness, particularly near the end of life. They are often included in palliative "comfort kits" and used for terminal sedation.

 

Key points regarding BZDs in palliative care:

Commonly Used Agents

Midazolam (often for subcutaneous/IV) and lorazepam are the most frequently used benzodiazepines in palliative settings.

Indications

They are primarily used for anxiety, panic, terminal agitation, insomnia, and dyspnea (breathlessness).

Palliative Sedation

BZDs, especially midazolam, are considered frontline medications for palliative sedation when symptoms are refractory.

Risks & Considerations

While beneficial for comfort, they can cause sedation, cognitive impairment, and falls, particularly in elderly or frail patients.

Duration

Short-term use is usually preferred, and in some, tapering may be considered, though in the final stages of life, this is not usually necessary.

 

Investigating - Lemborexant (Dayvigo)

Lemborexant, marketed as Dayvigo, is a prescription medication used to treat insomnia in adults.  Here's a summary of key information about Dayvigo:

 

Mechanism of Action

Dayvigo is an orexin receptor antagonist that works by blocking wake-promoting chemicals in the brain to reduce wakefulness and promote sleep.

 

Indications

It is used to treat insomnia characterized by difficulty falling and/or staying asleep.

 

Dosage

The recommended dose is 5 mg nightly before bed, with at least 7 hours remaining before planned awakening, and can be increased to a maximum of 10 mg based on need and tolerability.

 

Administration

It should be taken right before going to bed with at least 7 hours before planned awakening, and taking it with or soon after a meal may delay its effects.

 

Contraindications

Dayvigo is contraindicated in patients with narcolepsy and severe hepatic impairment, and should not be taken with strong CYP3A inhibitors.

 

Warnings and Precautions

Dayvigo can cause daytime drowsiness and impaired coordination, especially with higher doses or when combined with other CNS depressants like alcohol. It may also lead to complex sleep behaviors, worsen depression, or increase the risk of suicidal thoughts. It is contraindicated in narcolepsy due to the risk of worsening symptoms.

 

Side Effects

Common side effects include sleepiness, fatigue, headache, and nightmares. More serious effects can include hallucinations, suicidal thoughts, allergic reactions, and unusual sleep behaviors.

 

Drug Interactions:

Dayvigo can interact with various medications and substances, including alcohol and certain CYP3A inhibitors. Grapefruit and grapefruit juice should be avoided.

Effectiveness

Clinical trials have shown improvements in sleep onset and maintenance.

User Experiences

Some users report positive experiences with faster sleep onset and improved sleep quality, while others experience negative effects like sleep paralysis, hallucinations, or lack of effectiveness.

Alternatives - EOL Considerations

“Euthanasia and permanent hospitalization present contrasting approaches to end-of-life care, each with its own set of ethical and practical implications. Euthanasia, when legal, offers a controlled and often rapid death, allowing individuals to choose the timing and method of their passing, typically in cases of terminal illness or unbearable suffering. Permanent hospitalization, on the other hand, focuses on providing extended medical and emotional support for individuals who may not be able to care for themselves or whose conditions require long-term management.”

 

MAID: Medical Aid in Dying

https://www.britannica.com/procon/MAID-medical-aid-in-dying-debate

Should Medical Aid in Dying Be Legal?

Last Updated: May 6, 2025

Medical aid in dying (MAID) is also called medical assistance in dying, physician-assisted suicide (PAS), physician-assisted death/dying (PAD), and self-determination in dying. The New York State Bar Association defined MAID as “when a terminally ill, mentally competent adult patient, who is likely to die within six months, takes prescribed medicines, which must be self-administered, to end suffering and achieve a peaceful death.”

 

MAiD in California

Medical Aid in Dying (MAID): A legal process under the California End of Life Option Act for terminally ill adults to request life-ending medication.

Key Requirements

To be eligible for MAID in California, an individual must meet the following criteria:

Be 18 years or older and a resident of California.

Have a terminal disease that is incurable and irreversible, with a medical prognosis of death within six months.

Possess the mental capacity to make medical decisions.

Be able to self-administer the aid-in-dying medication.

 

The Process

The process involves multiple steps and is entirely voluntary for both patients and healthcare providers.

Initial Oral Request

The patient makes a first verbal request to their attending physician.

Consulting Physician Review

A second consulting physician must confirm the terminal diagnosis and the patient's eligibility.

Written Request

The patient provides a signed, written request form, witnessed by two individuals.

Second Oral Request

A second verbal request must be made at least 48 hours after the first one.

Prescription & Ingestion

The physician writes the prescription, which the patient then self-administers at a private place and time of their choosing.  Further information is available through resources like End of Life Choices California or the California Department of Public Health.

 

Euthanasia

MAID differs from euthanasia, which is when a healthcare provider administers a fatal drug, and from passive euthanasia, which is when artificial life support is withheld or stopped (such as feeding tubes and ventilators). Euthanasia is illegal in the United States but legal in some countries, including Belgium, Canada, Luxembourg, the Netherlands, and Spain.

 

Mentally Competent Older Adult

A mentally competent older adult is generally defined as someone who can understand the information relevant to a decision, appreciate the potential consequences, and make a rational choice. This includes the ability to comprehend information, understand its importance, make sound judgments among available options, and consider the potential impact of their decisions.

 

• Comprehend information
• Understand its importance
• Make sound judgments among available options
• Consider the potential impact of their decisions

 

Who makes decisions for a mentally incompetent adult?

Decisions for a mentally incompetent adult are typically made by a court-appointed guardian or conservator when the individual can no longer manage their own affairs. If no prior legal documents exist, a judge determines the need for a guardian based on evidence of incapacity.

Key Decision-Makers and Mechanisms

Court-Appointed Guardian/Conservator

A person appointed to manage personal care (guardian) or financial affairs (conservator).

Power of Attorney (POA)

If designated before incapacity, a chosen agent (financial or healthcare) acts for the adult without court intervention.

Healthcare Proxy/Surrogate

A person authorized to make medical decisions when the patient cannot.

Process for Determining Incapacity

Legal Determination

Only a court can declare an adult legally incapacitated, usually requiring evidence from a physician.

Alternatives

Courts prefer less restrictive options, such as supported decision-making, before appointing a guardian.

Scope

The court may grant full (plenary) or limited guardianship depending on the individual's specific needs. When no family is available, a professional guardian may be appointed.

 

Evidence of incapacity

How is Incapacity Determined? - Vasquez de Lara Group

Evidence of incapacity requires, at minimum, documented, consistent, and recent proof of severe mental or physical impairment that prevents a person from managing their own affairs. It is typically established through medical reports, expert testimony, and accounts of consistent, irrational, or dangerous behavior, rather than isolated incidents of confusion.

Sleep and Suffering

Yes, sustained sleep deprivation can be considered a form of suffering. It leads to a wide range of negative physical and mental health consequences.

 

Elaboration - Physical Health

Sleep deprivation can negatively impact various bodily systems, including the cardiovascular, metabolic, and immune systems. It's linked to increased risk of heart disease, type 2 diabetes, obesity, and weakened immune function.

 

Mental Health

Lack of sleep can severely impact cognitive function, making it difficult to learn, focus, and make decisions. It can also trigger mood changes, anxiety, and even depression.

 

Overall Quality of Life

Sustained sleep deprivation reduces overall quality of life, affecting daily activities, work performance, and social interactions. It can also lead to a greater likelihood of accidents and injuries.

 

Sleep and Mental suffering

Sleep deprivation can cause significant mental suffering due to the impact on cognitive abilities, emotional regulation, and overall well-being.  In summary, sustained sleep deprivation is not just a temporary inconvenience; it can have long-lasting and detrimental effects on physical and mental health, leading to a state of suffering.

 

Can AI determine efficacious medications?

One of the key applications of AI in medicinal chemistry is the prediction of the efficacy and toxicity of potential drug compounds. Classical protocols of drug discovery often rely on labor-intensive and time-consuming experimentation to assess the potential effects of a compound on the human body.

 

Replacing Ambien

Several alternatives to Ambien (zolpidem) can help with insomnia. These include:

 

Prescription Medications

 

Lunesta (eszopiclone): Similar to Ambien, but may have a longer duration of action.

Sonata (zaleplon): A shorter-acting sedative that can help with sleep onset.

Restoril (temazepam): A benzodiazepine that can help with both sleep onset and maintenance.

Dayvigo (lemborexant): A newer medication that works differently than Ambien and may have a lower risk of dependence.

^>Trazodone: An antidepressant that can also be used as a sedative for insomnia. [Trazodone has proven ineffective for Buster with regards to sleep].

 

Over-the-Counter Medications:

Melatonin: A hormone that helps regulate sleep-wake cycles.

Diphenhydramine (Benadryl): An antihistamine that can have sedative effects.

 

Other Options

Lifestyle changes

.

Establishing a regular sleep schedule [Done], avoiding caffeine [Done] and alcohol [Done] before bed, and creating a relaxing bedtime routine [SoSo] can help improve sleep quality.

 

Cognitive behavioral therapy (CBT-I).

A type of therapy that can help patients identify and change behaviors that contribute to insomnia. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a highly effective, structured, short-term (typically 6-8 sessions) non-drug treatment recommended as the first-line, long-term solution for chronic sleep issues. It addresses the underlying thoughts, habits, and behaviors contributing to sleeplessness rather than just symptoms. Key techniques include:

 

Stimulus Control: Associating the bed only with sleep.

Sleep Restriction: Limiting time in bed to increase sleep drive.

Cognitive Restructuring: Changing anxiety-inducing thoughts about sleep.

Sleep Hygiene: Improving environmental and lifestyle factors.

 

Natural Remedies.

Some people find relief from insomnia with supplements like magnesium, valerian root, or chamomile tea.  It's important to note that these alternatives may have different side effects and risks than Ambien. It's crucial to consult with a healthcare professional to determine the best option for your individual needs.

 

Natural Sleep Chemicals

 

Adenosine

This neurotransmitter accumulates during wakefulness and promotes sleep. It's also believed to prolong deep sleep. Adenosine is an inhibitory neurotransmitter and metabolic byproduct that functions as a primary homeostatic sleep regulator, accumulating in the brain (especially the basal forebrain) during wakefulness to increase "sleep pressure". It promotes sleep by inhibiting arousal systems and, once asleep, helps prolong deep (slow-wave) sleep.

 

Melatonin

A hormone that regulates the sleep-wake cycle and can be used to help with sleep disorders like jet lag or shift work.

 

GABA

An inhibitory neurotransmitter that helps reduce brain activity and promote muscle relaxation, especially during deeper sleep.

 

Chemical Sleep Aids (Medications)

 

Benzodiazepines

These can be effective for short-term sleep problems, but long-term use can lead to dependency, memory impairment, and tolerance.

 

Antihistamine

Some, like diphenhydramine (Benadryl), are used in over-the-counter sleep aids, but can have side effects like daytime drowsiness, cognitive impairment, and potential risks for older adults.

 

Off-label use

While certain medications (antipsychotics, anticonvulsants) are sometimes used off-label for sleep, there's less data on their safety and effectiveness for sleep disorders.

 

Long-term Risks

Interference with Natural Sleep-Wake Cycle: Prolonged use of chemical aids can disrupt the body's natural ability to regulate sleep, potentially leading to dependence.

 

FYI - Disrupted natural ability to regulate sleep – Not Applicable

A disrupted natural ability to regulate sleep often manifests as narcolepsy, a chronic neurological disorder where the brain cannot properly control sleep-wake cycles. It involves a loss of hypocretin/orexin, essential neurochemicals for maintaining wakefulness. Key features include excessive daytime sleepiness, sudden sleep attacks, and uncontrollable sleep-wake transitions.

 

Tolerance and Dependence

The body can develop a tolerance to sleep aids, requiring higher doses to achieve the same effect, which can lead to dependence.

 

Side Effects

These can vary depending on the specific chemical, but may include drowsiness, memory problems, and cognitive impairment.

 

Potential for Long-term Health Issues

In some cases, long-term use of certain sleep aids may be associated with an increased risk of certain health problems, such as dementia.

 

Important Note

If you are struggling with sleep, it's important to consult with a healthcare professional. They can help determine the underlying cause of your sleep problems and recommend appropriate treatment options, which may include behavioral therapies, medication, or lifestyle changes.

 

Lorazepam

Lorazepam (brand name Ativan) is a short-term, prescription-only benzodiazepine used to treat insomnia related to anxiety or temporary stress. By increasing GABA in the brain, it induces sedation, typically taken at a dosage of \(1\{mg}\) to \(2\{mg}\) at bedtime. It is generally recommended for short-term use due to risks of dependency and side effects. 

 

Gamma-aminobutyric Acid (GABA) Deficiency

GABA (gamma-aminobutyric acid) is a key inhibitory neurotransmitter that plays a vital role in regulating brain activity and promoting relaxation. A deficiency in GABA can disrupt this calming effect, potentially leading to various neurological and psychological conditions.

Causes

Genetic disorders: Certain genetic mutations can impair the production or function of GABA. Medications: Some medications, such as benzodiazepines, can deplete GABA levels over time. Chronic stress: Prolonged stress can lead to reduced GABA production.

Alcohol abuse: Excessive alcohol consumption can interfere with GABA synthesis.

Nutritional deficiencies: Deficiencies in vitamins B6, magnesium, and zinc can affect GABA production.

 

Symptoms:

1.     Anxiety and panic attacks: GABA deficiency can increase anxiety and make individuals more susceptible to panic attacks.

2.     Mood disorders:

a.     Depression, irritability, and mood swings can be associated with low GABA levels.

3.     Sleep disturbances:

a.     Insomnia, restless sleep, and nightmares can occur.

4.     Seizures

a.     In severe cases, GABA deficiency can trigger seizures.

5.     Muscle spasms and tremors: GABA helps regulate muscle activity, so deficiency can lead to muscle spasms and tremors.

6.     Cognitive impairment:

a.     Difficulty concentrating, memory problems, and confusion can be experienced.

 

Diagnosis

 

1.     Blood test:

a.     A blood test can measure GABA levels.

2.     Brain imaging:

a.     Techniques such as MRI or PET scans can assess GABA activity in the brain.

3.     Genetic testing:

a.     Genetic tests can identify genetic mutations associated with GABA deficiency.

 

Gamma-aminobutyric Acid (GABA) Deficiency (Continued)

Treatment

Medications

GABA agonists, such as benzodiazepines and valium, can increase GABA levels.

Nutritional supplements:

B vitamins, magnesium, and zinc supplements can support GABA production.

 

Lifestyle changes

Reducing stress

Limiting alcohol consumption

Getting enough sleep can improve GABA function.

 

Therapy

 

Cognitive Behavioral Therapy	Cognitive behavioral therapy (CBT) can help individuals manage anxiety and other symptoms associated with GABA deficiency.
GABA	The prognosis for GABA deficiency depends on the underlying cause and severity of symptoms.

 

Aside - Valium

Valium (diazepam) is a benzodiazepine, a class of central nervous system depressant drugs used to treat anxiety, seizures, muscle spasms, and alcohol withdrawal symptoms by slowing down brain activity. It works by enhancing the effects of GABA, a calming neurotransmitter, leading to sedative, relaxing, and anti-seizure effects. Due to its potential for dependence and misuse, it's typically prescribed for short-term use.

 

Conclusion – In our own words (Partial Bios)

>This study pertains specifically to Keith “Buster” Torkelson, MS.  Buster holds a degree with honors in pathology out of UC Davis.  Buster has been diagnosed many times with behavioral health ailments including: Bi-polar, Depression, Schizoaffective, Sleep Disorder, Psychosis, Anxiety, Panic and Hypo-mania.  Buster was first hospitalized in 1989.  At this time his doctors told him that causes do not matter and that he would never get better.  In 1988 Buster fell ill in association with an immune response gone wrong.  Buster had been depriving himself of sleep in order to make grades since 1982.  This was a risk factor for Buster to develop a sickness or sicknesses.  Centering about health limbo (1993) Buster had a problematic youth,  succeeded working full time, completing undergraduate, interning in food animal population health, completing his master’s, gaining entrance to Vet School, getting sick, returning and making grades in vet school,  serious life threatening episode 1993, entering into recovery,  helping run the family business,  attending CSU Fullerton secondary teaching credential program, making transition to renting a shared room,  4.0 earned at Cypress College, 2012 crash and burn, etc.  The takeaway is: Leverage an early diagnosis and treat effectively with the intent to resolve the issue as measured by gainful employment and education.