Nathaniel F. Watson, MD

I’ve learned so much from you 2. I’m someone who has a sleep disorder with restless legs, going right into REM [rapid eye movement] sleep, and sleep paralysis, with some family members who have the same. Where are some of the resources? Where can I get help? Where can I turn to if my primary care doctor isn’t talking to me about it? Are there resources on the internet that I can look at?

 I start with the primary care physician to see if they have a referral reference in place. A lot of them will have sleep physicians in the area that they trust, or physicians that they have referred patients to if they’re not able to handle it. If they don’t have time to handle it, they’re usually happy to refer you to a sleep specialist. That’s the best approach. I don’t love sending patients to the internet. It’s not because there’s not accurate information there. There’s way too much information there, and then you’re letting them pick and choose what to read, what to follow, and what to believe. That requires a lot of guidance.

People will bring me printed articles and say, “What do you think about this?” I appreciate that so that we can have an intelligent conversation about it, but there’s not 1 specific place to go to. Most people just google: “I sleep bad,” or “insomnia,” or “how do I sleep better?” Then they get ads for marijuana and CBD [cannabidiol] oil, and it creates so much anxiety because then they start reading about the complications of insomnia. If it’s done in an office setting with a sleep specialist—someone who’s been trained to deal with this—they can gain some perspective and education personalized to their situation. As opposed to going on Google and reading anything that may not be very comprehensible to everybody. If insomnia is the issue, I’d rather have patients speak to a sleep specialist or a sleep psychologist to get the history and direct them the right place.

If I’m in an underserved area, 5000 miles away from a big city, and there’s not someone in my area, is there a way to get directly in touch with a sleep specialist? Or do you have to go through the primary care doctor?

 There are a couple of things. One is sleepeducation.org, which is an AASM [American Academy of Sleep Medicine]–curated website that has good information. It helps you avoid Dr Google, which can send you into that spiral. There are huge swaths of the country that have no sleep medicine expertise. The pandemic increased the amount of telemedicine we do. In fact, we offer in-person or telemedicine to all our patients now, and a slight majority prefer telemedicine. That’s opened things up a little for individuals in rural areas, where the expertise doesn’t exist or where they may not be able to travel to the metropolitan centers that have sleep doctors.

There’s a lot of direct-to-consumer entities developing that are FDA approved that can screen, diagnose, and help with the treatment of sleep apnea. You have to reconsider the model of sleep apnea diagnosis and care. In some instances, board-certified sleep doctors are still involved in the interpretation of the test. The test isn’t always a completely traditional, at-home sleep apnea test or a laboratory-based polysomnogram, but they’re validated, FDA approved, and fairly accurate. This is potentially paid for out of pocket by the patient, as opposed to having insurance cover it, but it’s a pathway to get their problem identified and treated. There are at least 4 or 5 entities that provide a…sleep assessment and treatment.

I want to thank both of you. As a non–sleep specialist and a curious patient, I learned so much. If you enjoyed this conversation, please subscribe to our e-newsletters. You can learn about upcoming 

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Drs C. Michael Gibson, Ashgan A. Elshinawy, and Nathaniel F. Watson share resources for the treatment of sleep disorders.

Resources for Sleep Disorders

Let’s talk about unmet needs. Obviously, people need to wake up to sleep disorders. It was fun to hear you say that it’s an exciting time in sleep because we usually think of sleep as something not exciting. What are some of the big unmet needs? What do we need to do?

 Sleep deprivation is the most common cause of sleepiness in our society. We have to find ways to encourage people to prioritize sleep. When there are many competing interests for their time, I try to get the patient to focus on the quality of their wakefulness experience as opposed to the quantity of their wakefulness experience, and that seems to resonate with patients when I discuss that with them. Other unmet needs include the sleep medicine physician shortage in the United States. We need to expand the specialty. The American Academy of Sleep Medicine and other organizations are working to expand fellowship programs, bring more trainees into sleep medicine, and improve access to care across the board.

We live in a time where 80% to 85% of patients with sleep disorder breathing never cross the threshold of a sleep disorder center to get the problem diagnosed and treated. That’s a real problem when we know how much of a positive impact we can have on the quality of life for these individuals. It’s such a missed opportunity. We have to figure out a way to tackle and solve that problem. It’s been difficult to engage other specialties in the care of sleep medicine. On the bright side, cardiologists such as yourselves are embracing the notion of paying attention to sleep disorders and sleep problems. I know that there are some entities developing products. That could be a cross between a Holter monitor and a sleep monitor, for instance. Hopefully, we’ll have technologies that can be used by other specialties, like cardiology and sleep medicine, to bring these groups together and to have discussions, so we can make sure that appropriate referrals are landing on our desk. It’s a challenging time in many ways. We have to continue to convince anyone who listens to us that healthy sleep is the way to a healthy, happy life.

From your perspective, Ashgan, what are some of the unmet needs?

We have to remove the barrier to discussing sleep with patients. Time is a huge factor, especially in private practice. A lot of people don’t take the time, or they’re afraid to ask about sleep. A lot of practitioners won’t even go near it because they’re afraid that the patient is going to say, “Yes, I have a horrible sleep problem,” and they won’t know how to address it.

That’s true. They’re scared of it. They’re scared that someone is going to ask for benzodiazepine.

 They get stuck prescribing it and refilling it. I’m friends with a lot of primary care physicians. They’ll say, “I don’t want to get stuck filling prescriptions that I’m not comfortable filling.” In New Jersey, where we are, there are certain medications that you can’t even give beyond 5 days. Then what? You’ve solved the problem for 5 days, but you have to figure out the long-term solution. It’s a time commitment and an education commitment.

It’s very important to destigmatize sleep problems. Patients often equate sleep disorders, insomnia, or sleep apnea with something they did wrong. I may not be sleeping well because of my bad habits or because of something I did or didn’t do. Or they ask if they’re doing it incorrectly. They’re almost afraid or embarrassed to admit it to their doctors. Even when they’re asked about it, they say no. They brush it off and say it’s fine. But the doctor has to be a little more in-depth and say that your blood pressure is out of control. You’re having headaches way too often. You have moodiness, and your relationships are suffering. Are you sure your sleep is OK? They have to push it and ask targeted questions, rather than just, how’s your sleep? Most of them will that it’s OK because they don’t want to delve deeper. It goes back to a lot of communication. Take an extra 2 to 3 minutes. You can always address it more on a subsequent visit if there’s not enough time, but at least you’ve flagged that as being a very significant concern for that patient.

The DORA isn’t predictive, right? That would help alleviate some of this concern about addiction. Is that true?

 Yeah. The data that Dr Watson was reviewing with us about these agents are 1-year data and an extension trial. They show that it’s not habit forming. They don’t have withdrawal symptoms if you discontinue the medication. Whether it’s that category of medicine or another that I choose for the patient, I always point that out because that’s 1 of their biggest concerns. You hit the nail in the head: they’re afraid. They’re asking, “Am I going to get addicted to this? Am I going to have to use this for the rest of my life? Am I never going to be able to come off it for a night or 2?” I always try to educate them about the drug—the half-life, how much of a habit-forming risk there is with this drug. It puts them at ease. Even if there’s some risk, they’re empowered by knowing what they’re getting themselves into. As a sleep practitioner, I try to steer away from any habit-forming medications.

 DORAs should be taken nightly. They curtail wakefulness. They’re not a general sedative. Particularly with…the adverse effects were fairly comparable to the placebo. As far as primary care physicians are concerned, they should view this class of medication as a breakthrough and be a bit more comfortable managing insomnia with these medications, as opposed to some of these others—particularly benzodiazepines, which can be problematic from a number of perspectives. One thing that’s important to realize with the…is that there’s no recommended starting dose and no titration schedule. In the many pivotal trials, 35% to 40% of individuals were age 65 and older. That can give people some comfort in prescribing this medication in some of our older patients.

As far as sleep apnea is concerned, some newer things coming out might make it easier to think about managing in primary care settings. There’s a TENS [transcutaneous electrical stimulation therapy] unit that can strengthen the slow-twitch muscle fibers in the tongue to address this. There’s potential development of a medication in clinical trials for sleep apnea. There’s nothing imminent that I’m aware of, but there may be in the next 5 years or so. It’s worth noting for our primary care colleagues that the management of sleep disorders is going to become something more accessible to them in their practices.

Nathaniel F. Watson, MD, leads a discussion on gaps in care and unmet needs for patients and healthcare professionals in the area of sleep disorders.

Unmet Needs in Sleep Disorder Management

What's coming down the pipe? What are you excited about in the world of insomnia?

: The consumer sleep technologies that are out there. We live in this age of the quantified self, and if you can measure it, you can manage it. People can now measure their sleep. They can make positive change in their life, whether it's a more consistent sleep schedule, a new sleep environment, or a new exercise regimen, and see what impact that has on their sleep duration and sleep quality. These devices are reasonably accurate. Their biggest challenge is differentiating quiet wakefulness from lighter stages of sleep, but they do give a reasonable assessment of night-to-night variability in sleep quality and sleep duration. The other important point here is that for the longest time we were only able to measure sleep 1 night in a strange sleep environment, and that is nowhere near an adequate representation of a person's sleep life. Now, we can monitor sleep nightly in their typical sleep environment for weeks, months, years, and we get a much better understanding of what's going on with their sleep. Some of these technologies have guides or advice that's available. They may be assessing caffeine intake, alcohol intake, exercise, or stress levels. Then, they begin to understand that when you do those certain things and have those behaviors, your sleep is worse, so they can council you about that. They can also look at the erratic timing of your sleep and help to create a more consistent sleep schedule. Some of these devices have advice engines that patients can use, or people can use to improve their sleep without even having to cross the threshold of a sleep disorder center. We talked about cognitive behavioral therapy for insomnia and the first-line treatment works really well, but there's a limited number of practitioners who can apply it. There are digital CBT-I solutions now that are out there that are FDA approved, and I'm interested to see if that increases access to this therapeutic modality for people. Beyond that, there's things like what's called binaural beats, where if you play tones of different frequencies in each ear, the superior olive in the brain interprets that as the difference between the 2 tones and creates a tone of a new frequency that can be linked up to your EEG. Then, you can manipulate the tones to slow down the EEG, which is what happens when we fall asleep. We'll have to see what happens with that, and then, there's some technologies that use something called device-guided breathing, but basically use a number of different metrics in order to slow a person's respiratory rate down. This is one of the things that we naturally do to help us fall asleep. That's another exciting new technology that's out there. We have a lot of things that people can use to help them sleep better.

: I'm very grateful that at-home sleep testing has become so prevalent. It takes a lot to convince a patient to have a sleep sitting in a sleep center, and get dressed up as robots for the night, and sleep in a different environment like Nate alluded to. I'm able to rule out the most common sleep disorders before I can say, ‘OK your 5 awakenings at night are definitely just insomnia, your pain, or something else other than sleep apnea.’ I can get that out of the way before I give them pharmacologic therapy that's going to sedate them further and make their sleep disorder breathing worse. It's so prevalent and it's so easy. I remember when I was doing my sleep fellowship at NYU many years ago. We were just starting to study at-home sleep testing, and I was involved in getting the ARES device validated and tested, which was a novel thing. Is [this] going to become a thing, or not, and now, it's covered and so accessible to patients. They welcome it, they want to do the study, and we're able to get so much information at a much cheaper cost, which is great for our health care system and gives us a lot of information. I appreciate having these panels with people like you, but we need to continue stuff like this to educate our peers in all specialties so that they can be more familiar and aware of these sleep disorders and the simple screening tools we have available to uncover these disorders that are causing a lot of morbidity for our patients.

: Another thing, as we talk about the future, is the impact of artificial intelligence on sleep. We're seeing auto scoring overnight sleep studies, which it's useful for that. We're realizing that we're talking about screening for sleep disorders before, and how we wish more of it would occur. You can use machine learning algorithms to assess an EMR within a health system to flag people that have a high risk of sleep apnea without having to ask them specific sleep apnea risk-related questions. Once those individuals are flagged, it's kind of like that automatic referral can occur, rather than having to take the time of the primary care doctor to look into it, and they may not think of it. Beyond that, they can identify which patients are going to struggle with their therapy and identify these people sooner in order to intervene and to improve treatment adherence. Artificial intelligence, as we apply it to sleep medicine, is going to transform things in a lot of ways. Further down the line, we'll look more at cluster analysis and personalized treatment for specific sleep disorder phenotypes. We're not necessarily quite there yet, but as far as trying to identify the high-risk patient who is already in your health care system and consuming resources at a rate that if sleep disorders were treated, that these health care savings would be realized by health systems. We've done actuarial analysis to show substantial reductions in health care utilization once you address sleep disorders. All of the stakeholders will benefit from this. Patients will get better, health care systems will save money, and doctors will have better outcomes with their patients. It's an exciting time to be in sleep medicine.

It's great to see that we're bringing the sleep lab to the home, and empowering patients with all of these new devices and wearables.

Experts in sleep medicine share emerging treatments in the pipeline for the management of sleep disorders.

Emerging Treatment Options for Sleep Disorders

One of the problems that we have in cardiology is adherence. Although we have drugs that save lives and improve the quality of life, we've done some studies that show 30% of the time people don't fill the prescription. Some of this is because it's a silent killer. Obviously, sleep disorders and insomnia impact people directly, but do you have problems with adherence in this field? Do some of the new drugs, like daridorexant, have less of that hangover effect? Are they better tolerated, are people more adherent, and does that factor into your treatment decisions?

: It goes back to communication and education with the patient. They're so vital. You have to set the expectations at the beginning. Before I ever prescribe a medication, I want complete ownership by the patient. I want them to be a team player in making this decision. I almost want them to come to the decision even before I do because that will enhance the adherence and the commitment to the therapy. I also educate them about the pluses, minuses, and the alternatives of this therapy. We have a conversation about how it's not a prescription “on-your-way-out” type of thing. That's where you'll see the low adherence especially with cardiology, since there's a lot of frequent dosing during the day, and that makes it definitely more difficult to adhere to therapy. With sleep, fortunately, it's a 1 time a day drug, and they usually remember it because they're obsessing already about sleep and they know to take that drug. Specifically with the DORAs, it may be a little bit more challenging because it's not a “knock you out” medication, and it would be very hard for them to adhere to it, if they are not educated beforehand that this is not going to necessarily knock you out the first night, second night, or ever. It's going to enhance these parameters, and these are the parameters that we're going to follow together. I say, “That's why I see you in a couple of weeks,” or 3 weeks, and we'll talk about it so I can hold your hand going through the therapy. They have to know that you're partnering with them and that you're not just giving them a prescription and seeing them in 6 months.

: This is another role for the consumer sleep technologies that we talked about before. Not only identifying sleep problems, but also providing objective evidence to the individual that the treatment plan that they're enacting is actually working the way it's intended. Unfortunately, in regard to sleep, people aren't always able to subjectively assess the quality of their sleep, or duration as well as we would hope because you're unconscious while you're sleeping, so how would you really know how well your sleep was. With these technologies longitudinally over time, people could compare what their numbers look like after starting a treatment compared to previously and that can be a powerful motivator for somebody to stick with a medication in the long term, but sleep medicine is certainly not immune to the problems with treatment adherence. We must continue conversations with people to explore what their challenges are, and then, help them overcome those hurdles. Last thing, in regard to daridorexant, is that subjective total sleep time was one of the secondary outcomes, and there was a 60 minute or so improvement in that in regard to that medication, despite the challenges of being able to successfully assess your sleep quality or duration. The patients that were taking that did notice a substantial increase in the duration of their sleep at night.

It sounds like less of a hangover in the morning. What do you do about people who have memory problems, such as those who may not even remember to take their sleeping agent at night? Are there apps out there that you can use to help remind the person to take their medicine, or to engage family members in improving adherence?

: In general, that can apply to any medication, or any therapy. I often will involve family members usually if somebody's memory is impacted, or if there's any element of dementia. They're typically not living alone. In the rare situation that they are, we use audio reminders, setting an alarm to go off. Especially for my older patients, their older children will actually call them at a certain time and say, “Mom it's time to take this medicine,” or we'll do a Facetime discussion until they get the hang of it on their own. I have done that with both respiratory and sleep treatment, and that's usually very effective, but they need a support system and someone involved to help them.

Let's talk a little bit about unmet needs. Obviously, people need to wake up to sleep disorders. We think of sleep as something not exciting, but what are some of the big unmet needs? What do we need to do?

: Sleep deprivation is the most common cause of sleepiness in our society, and we have to find ways to encourage people to prioritize sleep in their life when there are so many competing interests for their time, and what I do is I try to get the patient to focus on the quality of their wakefulness experience. As opposed to the quantity of their wakefulness experience, that seems to resonate with patients when I discuss that with them. We have a sleep medicine physician shortage in this country, so we need to grow the specialty and I know that the American Academy of Sleep Medicine and other organizations are working to grow fellowship programs, bring more trainees into sleep medicine, and to improve access to care across the board. We live in a time where 80 to 85% of patients with sleep disorder breathing never cross the threshold of a sleep disorder center to get the problem diagnosed and treated. That's a real problem when we know how much of a positive impact we can have on the quality of life for these individuals. It's such a missed opportunity, and we have to figure out a way to tackle and solve that problem, which has been somewhat recalcitrant to our efforts to engage other specialties in the care of sleep medicine. On the bright side, cardiologists such as yourselves are embracing the notion of paying attention to sleep disorders and sleep problems. I know that there [are] currently some entities developing products that could be a cross between a Holter monitor and a sleep monitor, for instance. Hopefully, we'll have technologies that can be used by other specialties like cardiology and sleep medicine in order to bring these groups together to have discussions and to make sure that appropriate referrals are landing on our desk. It is a challenging time in many ways. We have to continue to convince anyone who listens to us that healthy sleep is the way to a healthy, happy life.

Drs C. Michael Gibson, Ashgan A. Elshinawy, and Nathaniel F. Watson examine setting treatment expectations with patients and treatment adherence for sleep disorders.

Nathaniel F. Watson, MD

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