Sleep Disorders and Health Conditions: Focus on Insomnia - Episode 13
Experts in sleep medicine share emerging treatments in the pipeline for the management of sleep disorders.
C. Michael Gibson, MD: What's coming down the pipe? What are you excited about in the world of insomnia?
Nathaniel F. Watson, MD: 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.
C. Michael Gibson, MD: Ashgan, what else is highly used?
Ashgan A. Elshinawy, DO: 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.
Nathaniel F. Watson, MD: 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.
C. Michael Gibson, MD: 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.
Transcript edited for clarity