Q&A: Helping patients get a better night’s sleep
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New data show that few Americans get a good night’s sleep, despite an abundance of literature showing the benefits of one.
Research shows that about 35% of working adults aged 18 years and older in the United States sleep less than the minimum recommended amount of 7 hours. A higher proportion of older adults get sufficient sleep — 72% — but only half of children and teenagers reach the 8 to 12 hours recommended by the AAP.
Failing to get the recommended amount of sleep — even for one night — can have serious health consequences, including an increased risk for anxiety and a greater likelihood of Alzheimer’s disease, according to researchers. To commemorate Sleep Awareness Week, Healio Primary Care asked Vikas Jain, MD, a board-certified sleep medicine physician and family medicine physician in Frisco, Texas, and an adjunct clinical assistant professor at Stanford University, to explain the role of the primary care physician in treating sleeping disorders and how physicians can help their patients get a good night’s sleep. – by Janel Miller
Q: Can you describe the PCP’s role in managing patients with sleep disorders such as insomnia, narcolepsy and obstructive sleep apnea?
A: PCPs are the first medical professional that most individuals are going to see, regardless of medical condition. Patients go to them both for preventive care as well as treatment or acute and chronic conditions. PCPs are usually the first individual with medical training who might be informed of a possible sleep disorder. Thus, PCPs often partner with other physicians in helping to identify which patients may need to see a sleep specialist for a more comprehensive sleep evaluation and management.
There are several screening tools available that can assist the PCP in determining if a patient may have a sleep disorder. One of the more commonly implemented screening tools is the Epworth Sleepiness Scale to gauge patient reports of excessive sleepiness. Some physicians will also use the Stop Bang questionnaire, which can be used to help screen patients for sleep apnea or risk for sleep apnea. Patients with abnormal scores on these tests, like a 10 and above on the Epworth scale, and a 3 and above on the Stop Bang questionnaire should be referred to a sleep medicine specialist. There are other validated instruments that could be implemented to track patients sleep quality over time such as the Pittsburgh Sleep Quality Index and/or the Patient-Reported Outcomes Measurement Information System sleep disturbance instrument. Often, obtaining a very brief sleep history or having patient’s keep a sleep diary/sleep log can also assist in identifying possible sleep issues.
It is always important to interpret the results of these screening tools in the context of the patient’s symptoms as the tools are not fool proof. For example, a patient with insomnia will often report feeling very sleepy; however, the primary complaint is the inability to actually fall asleep. Therefore, on a screening tool such as the Epworth Sleepiness Scale that asks for the likelihood that a person would fall asleep in eight different scenarios, patients will typically report a low score despite feeling excessively sleepy.
Q: Research indicates that treating sleep disorders in patients with dementia poses significant challenges. What are those challenges and how do you approach treating these patients?
A: One of the challenges in treating sleep disorders in patients with dementia is making sure that the patient understands the steps involved in implementing an intervention. In patients with obstructive sleep apnea that require the use of a continuous positive airway pressure, or CPAP, machine, it is important to understand if they will have any issues using and operating the machine independently.
Another challenge is prescribing medications. Many hypnotic medications have side effects that can impact memory or make a patient feel more groggy. There are studies that show hypnotic medications can also increase the risk of falls. Therefore, we want to be very careful in using these medicines in that patient population.
Q: What are some of the newer pharmacological treatments for sleep disorders, and which show the greatest potential?
A: The FDA recently approved Wakix [pitolsant, Harmony Biosciences] to treat excessive daytime sleepiness in adults with narcolepsy. The agency also recently approved Sunosi [solriamfetol, Jazz Pharmaceuticals] to treat excessive daytime sleepiness in adults with obstructive sleep apnea and/or narcolepsy. These drugs both act to increase alertness/wakefulness in patients who suffer from daytime sleepiness. For quite some time, we have not had many treatment options for patients with excessive sleepiness both with obstructive sleep apnea and/or narcolepsy, so it is exciting to have more treatments to help our patients.
Q: Studies have shown that nonpharmacological approaches like cognitive behavioral therapy and acupuncture may be effective in treating insomnia. What should a PCP consider when recommending these approaches?
A: PCPs and other members of the medical community should focus on patients improving their sleep habits and sleep behaviors vs. the quick fix that comes from sleeping pills. Pills are more for the short-term; a patient should not take more than 14 of them a month. Ideally, a patient’s ultimate goal is to learn how to sleep better on their own accord without the pills.
CBT for insomnia is actually very, very effective. In fact, it’s actually the gold standard for treating insomnia. Both the American Academy of Sleep Medicine and ACP have indicated that it should be utilized as an initial treatment intervention with patients with insomnia. Studies have shown that nondrug therapies such as acupuncture can also benefit patients with insomnia and if there are no contraindications, these treatments can be beneficial as well.
References:
AAP. American Academy of Pediatrics supports childhood sleep guidelines. Accessed March 2, 2020. https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Supports-Childhood-Sleep-Guidelines.aspx.
Driot D, et al. Therapie. 2019;doi:10.1016/j.therap.2019.03.004.
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Liu C, et al. Ann Palliat Med. 2020;doi:10.21037/apm.2019.11.15.
Low DV, et al. Am J Geriatr Psychiatry. 2019;doi:10.1016/j.jagp.2019.07.001.
Mansel JK, et al. Cancer J. 2014;doi:10.1097/PPO.0000000000000066.
Ram S, et al. Sleep Breath. 2010;doi:10.1007/s11325-009-0281-3.
Sleep Foundation. https://www.sleepfoundation.org/press-release/sleep-awareness-week-2020. Sleep Awareness Week. Accessed March 2, 2020.
Williamson AA, et al. JAMA Pediatr. 2019;doi:10.1001/jamapediatrics.2019.4806.
Disclosure: Jain reports serving on the speakers’ bureau for Jazz Pharmaceuticals.