Nighttime Agitation

NIGHTTIME AGITATION
by
Guardian Angel Laurie & Angel Teddy

INTRODUCTION:
If your epi pup is agitated and either cannot seem to fall asleep easily or stay asleep without waking up once or more during the night, you are not alone! This problem is one that visits many epi-pup parents, and it should be taken seriously, for at least two reasons:

1) Your pup needs his/her rest, and will be stressed out and more likely to have seizures if he/she cannot sleep well;

2) YOU need your rest, and will be stressed out and incapable of giving your pup the best care (not to mention be incapable of functioning in general) if you keep having your sleep interrupted.

I became interested in this problem when our Teddy suffered extreme nighttime agitation. My husband and I were up with Teddy 3-4 times every night, and both of us were constantly sleep deprived. Clearly Teddy was having a miserable time of it too.

MELATONIN helped Teddy a great deal, but did not entirely solve his problem. For many pups, melatonin is an excellent first choice, not only because it helps the pup to sleep, but also because, in some cases, it also decreases the frequency and/or strength of seizures. This is what happened for Teddy: he slept better and had fewer seizures and the ones he had were milder. For more on melatonin, see:

http://www.canine-epilepsy-guardian-angels.com/melatonin.htm

After investigating nighttime agitation further, and putting all of the
following into effect with our Teddy, he began to sleep all night long and did not wake us even once during the night. He also became seizure-free for two and a half years, before he passed from liver cancer.

CONSIDER MEDICAL CAUSES:
Most of us are so taken up with treating our pup's seizure disorder that we tend to blame it for everything. Many, if not most of our pups are immune-compromised and this fact alone will contribute to their getting certain medical conditions more frequently than non-epi pups (Levin 2002).

The first thing to consider, then, is that your pup may have a condition, perhaps only marginally related to the seizure disorder, that needs veterinary attention. The following list will help you observe your pup and discuss your observations with your vet. Our Teddy was a rescue pup and came to us with both ear infections and gum infections. Though these were treated by our vet, every time they recurred he would once again have problems sleeping. Teddy also experienced Dry Eye Syndrome, but his case was not advanced and did not disturb his sleep.

1) EAR INFECTIONS. If your pup shows any of the following: rubbing his/her head, pawing or scratching the ears, tipping the head to one side, pressing the head into your hands, seems off-balance, seems warm to the touch, or has an odor emitting from the ears, your pup may have an ear infection. Ear infections can be very painful and often seem to get worse at night. If you have any suspicion of an ear infection, take your pup to the vet.

2) TOOTH OR GUM INFECTIONS. Does your pup do any of the following: paw at the mouth, tip the head, seem reluctant to chew, not want you near his/her face, growl if you come near his/her head or face? If your pup will let you look in his/her mouth, open the mouth and carefully prod the gums near the tooth line, both outside and inside. Be careful! If there is pain, you may get bitten. Is there tenderness? Look at the gum line: is there redness or swelling? Are the teeth gummy with tartar? Is your pup's face sensitive to the touch? Some gum infections are not visible to the untrained eye. If you have any suspicion of a tooth or gum infection, take your pup to the vet.

3) EYE PROBLEMS. Epi-pups may be prone to Dry Eye Syndrome (reduced tear production) and Uveitis (inflammation of the iris, ciliary body, or choroid) (Levin 2002). One causes discomfort, the other pain. If you pup has "goopy eyes" (green or light brown mucous discharge), blinks a lot, has redness in the whites of the eyes, squints, rubs the face on the carpet or with the paws, you may be dealing with an eye problem. Take your pup to the vet.

4) MAKE SURE YOUR PUP IS UP TO DATE ON BLOOD CHEMISTRY PANELS, BILE ACID TESTS, AND BLOOD LEVEL CHECKS FOR ANY ANTI-EPILEPSY DRUGS (Pb, KBr, etc.) OR THYROID MEDICATIONS (Soloxine, Thyroxin).

Both blood chemistry panels with the liver enzymes GGT, ALT and Alkaline Phosphatase every 3 to 4 months and bile acid testing every 6 months are necessary to insure that your pup's liver remains healthy if he/she is on Pb. The Epi-Guardian Angels advise that you should have your pup tested with both tests to catch liver disease early.

All AEDs (anti-epilepsy drugs) and thyroid medications need to be checked regularly by your vet to make sure that they are at proper therapeutic levels, neither too high nor too low, in the bloodstream. If the levels are too low, your pup's agitation may in fact be pre-ictal behavior because he/she is about to have a seizure.

Although agitation is not a regular side-effect of Pb or KBr when they are at levels above therapeutic range, some pups may exhibit this, though it is not confined to nighttime only. In addition, too-high levels of Soloxine and other thyroid medications regularly cause agitation, but again this is not at night only. Similarly, some pups who are treated for cluster seizures may react to Valium with agitation, but this would occur only when the drug has been used.

NUTRITION FOR BETTER SLEEP:
In general, the healthier and more nutritious your pup's diet, the healthier your pup will be, and the better he/she will sleep. The Epi-Guardian Angels encourage home-prepared diets or the highest quality dog food, if you do not have the time to prepare the diet at home. If your pup's digestion is not compromised by a less than optimal diet, he/she will not experience a rise in cortisol (the stress hormone) that can be caused by foods to which the pup is allergic, or that are simply difficult to digest. The less stress, the less cortisol. The less cortisol, the better the sleep. The following are other nutritional considerations beyond providing a nutritious, easy-to-digest diet:

1) SNACKS TO SUSTAIN BLOOD SUGAR LEVELS
Some epis suffer from fluctuations in blood sugar and this may contribute to agitation and, ultimately, to seizures. If you notice your pup pacing between meals, or becoming otherwise agitated, small snacks throughout the day will help to keep the blood sugar stable and keep pacing and agitation at bay. A 1/2 to a whole meal right before bed works to calm nighttime agitation for many pups.

This should be a portion of the pup's regular food - something with high-quality protein and carbohydrate to sustain your pup throughout the night. The amount of protein should be lower than the amount of carbohydrate since protein contributes to energy, carbohydrate to sedation. Do not eliminate protein, however, because it helps sustain the blood sugar better than pure carbohydrate, which can lead to a rapid decline in blood sugar after an initial rise.

2) DEFICIENCIES OF VARIOUS MINERALS AND VITAMINS CAN CONTRIBUTE TO INSOMNIA
Since epi-pups often show deficiencies of certain minerals and vitamins, sometimes because of the use of AEDs that encourage depletion of these minerals and vitamins through polydipsia and polyuria (excessive drinking and urination), you may want to consider supplementation. The safest way to do this for minerals (which must be carefully balanced for good health) is by adding whole foods to your pup's diet (Levin 2002). It is NOT recommended that you give minerals as pill supplements, at least without the guidance of a professional. Discuss any program of supplementation first with your veterinarian.

Calcium, magnesium, manganese, potassium, and zinc are minerals whose deficiency can contribute to insomnia and/or nervous irritability (Mindell 1979). All of these can be safely supplemented by giving your pup pulverized (in a food processor) raw green and green leafy vegetables. Dogs cannot digest vegetables properly if they are given not pulverized. For best results, use a variety - romaine lettuce, green beans, celery. Avoid too many in the "cabbage" family (kale, collards, broccoli - anything that smells like cabbage - these in excess can interfere with thyroid function). For acid/alkaline balance (crucial for healthy bladders and urine), include a few root vegetables: carrots, turnips (only occasionally), parsnips, etc. Zinc, which is most plentiful in spinach of the green leafy vegetables, can also be found in broccoli, fish, meat, apples, and peanut butter. Rotate combined vegetables to get the best all-around variety.

B vitamins also aid in relaxation. Cortisol (the stress hormone) and AEDs are known to lower tissue levels of B vitamins as well as vitamins C and E. B vitamins are safely supplemented in pill form: for small dogs, use a "regular" dosage B multiple; for medium dogs, use a "high potency B 50" multiple; and for large dogs, use a "stress formula B 100" formulation (Dr. Clemmons, 2002, cited in Levin, 2002). A small amount of organic beef or chicken liver can also be given to supply B-vitamins. Since liver filters toxins, it is best to use only organic or at least "naturally raised."

COMMON SENSE FOR GOOD SLEEP:
The Stanford University Sleep Research Center (est. 1970) has done sleep testing on dogs and has discovered that dogs display many of the same sleep disorders as humans. It stands to reason, then, that some of the factors that help humans sleep better may help your pup. All of these have helped our Teddy immensely.

1) TURN LIGHTS LOW AS NIGHT PROGRESSES
Bright lights discourage melatonin production in the body, which can keep your pup from falling asleep easily or staying asleep. Start turning lights down at sundown, and if possible, keep them subdued throughout the evening.

2) DECREASE EXCITEMENT AND STRESS IN THE EVENING
Don't use nighttime hours to play with your pup, since even though this is enjoyable, your pup will likely experience a rise in cortisol (the stress hormone) that his/her compromised health cannot easily counteract. We noticed that when we would play with Teddy during the evening, he could not calm himself down like our other pups could easily do. Several hours later he would still be very excited. Similarly, try to keep family interactions calm and relaxing during evening hours. Keep voices low and avoid arguments to keep your pup from feeling stress and experiencing a rise in cortisol, which counteracts melatonin production and inhibits sleep. Music and TV should be kept at low volume. It is best to avoid anything that sounds agitated or raucous since this can cause stress to you pup, who cannot understand that this is not aimed at him/her.

3) PLAY SOFT, SOOTHING MUSIC AT BEDTIME
Soothing music, or any of the widely available "Sleep Soundly" type CDs were a godsend for our Teddy. Every night we turned on sleep-inducing CDs and put them on continuous play throughout the night. When Ted heard the music, he settled down and went to sleep. A nice side effect was that I, a lifelong insomniac, slept better than I had in decades!

4) HAVE A REGULAR BEDTIME, AND REGULAR TIME TO RISE, AND DON'T DEVIATE FROM THESE TIMES BY MORE THAN A HALF HOUR
The body develops rhythms that, if broken, make sleep more difficult to achieve. If you stay up some nights working long after bedtime, you may be disrupting your pup's ability to sleep soundly.

THE RIGHT PLACE: SEPARATION ANXIETY/"POWER SPOTS":
Many pups have a preferred spot for sleeping. Some pups like to be in the room with their "parents" and will feel anxious if separated, while others prefer their own space. I have never known a dog who did not have a few of what I call "power spots" in the house. These are the places to which they gravitate naturally: the places they most often choose to sleep if given a choice, whether during the day or at night.

If at all possible, let your pup sleep in a place where he/she feels most comfortable. Ideally, choose one of his/her favorite spots that is nearest to where you sleep, so that you can respond quickly to a seizure. For the pup's safety, make this an enclosed space that is clear of things into which he/she can bump or that he/she can pull down during a seizure. Knowing your pup is safe will help YOU to sleep.

When Teddy first came to live with us, I thought (for no good reason) he "should" be in the bedroom with the other dogs. But he felt more comfortable sleeping in the hallway right outside the bedroom. We therefore "baby-gated" him into this area, with access to the bedroom and kitchen. We pushed the kitchen table into a corner with the stools under it, so he could not pull these over on himself during a seizure. Teddy immediately began sleeping much more soundly once he had his own "spot" to sleep in.

One other thing that is worth a try if your pup appears anxious at night is (of all things) a T-shirt. To be effective, you will need one that fits snugly on your pup. You can "adjust" a slightly larger T-shirt by cutting it along the pup's back and tying the cut ends securely in a knot. Practitioners of Tellington Touch (T-Touch) recommend a fairly complicated wrap of Ace bandages to calm dogs, but a T-shirt works very well for many pups.

THE NEED TO ELIMINATE AND SLEEP DISRUPTION:
AEDs cause pups to drink more and therefore they need to urinate more often. While it is important to provide ample fresh water during the day, you can moderate the amount of water you give as night progresses to avoid your pup's having to eliminate during the night, which disturbs his/her sleep as well as yours, when you must see to his/her needs.

Another alternative is to provide a place for indoor elimination during the night. Although this may seem like a drastic solution, it may be better choice than constant sleep-deprivation. When our Ted was adjusting to KBr, and before he was taken off Pb, he often needed to eliminate many times during the night. We finally decided to provide crib mattress pads (which soak up a ton of urine and are easily washable) for nights when we were simply too tired to take him out one more time.

Hopefully these suggestions will help you and your pup get more sleep. We welcome feedback on how these ideas work for you as well as other suggestions not discussed here.

References:
Clemmons, R.M., "Seizure Disorders in Dogs and Cats,"
http://www.pawcare.com/rclemmons

Levin, Caroline D. Canine Epilepsy: An Owner's Guide to Living With and Without Seizures. Oregon City, OR: Lantern Publications, 2002.

Mindell, Earl. Earl Mindell's Vitamin Bible, 1979.

Pitcairn, Richard H., DVM, Ph.D., and Susan Hubble Pitcairn. Dr. Pitcairn's Complete Guide to Natural Health for Dogs & Cats. Emmaus, PA: Rodale Press, 1995.