Insomnia in Clinical Practice

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP Hello, everyone, and welcome to this HCPLive® presentation, Advanced Practice Providers’ Perspectives on Sleep Disorders, Insomnia: The Impact on Patient Health. My name is Dr Wendy Wright, and I am an adult and family nurse practitioner and the owner of 2 nurse practitioner-owned and operated primary care clinics. I’m located in Amherst, New Hampshire. We service about 6,500 primary care patients, and I have 11 nurse practitioners who work alongside me. It is my pleasure to be here with you today. And joining me today is Debbie Davis, an adult and acute care nurse practitioner from South Baldwin Medical Group in Foley, Alabama. Debbie, thank you so much for joining me.

Debra Davis, CRNP: Thank you for having me. Just to tell you a little bit about me I started out as an adult acute nurse practitioner, and then a compounding pharmacy asked me what I knew about bioidentical hormones, and I said, “less than nothing.” So, it sent me on a big adventure. I went to the American Society of Anti-Aging Medicine in Boca Raton, Florida and spent 5 years getting nationally certified in hormone replacement therapy for men and women and I took a few other courses, and now 80% to 90% of my practice is dealing with hormones.

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Thank you so much. We’re going to talk a little bit about sleep, and I suspect that you’ve had some experience with insomnia. We’re going to discuss the co-occurrence of sleep disorders with several other health conditions, and patient awareness and the importance of screening for these disorders. We’ll also discuss the treatment landscape for insomnia and the use of what are known as dual orexin receptor antagonists in the management of insomnia. Thank you so much for joining us.

To set the stage, I want to talk a little bit about the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, 5th ed.] diagnostic criteria for insomnia. And then, Debbie, I’m going to open it up and ask you a few questions and we’ll dialogue back and forth for our colleagues who are listening.

Generally, insomnia used to be thought of as a disease that was often related to other conditions, and we know that for many people that is true. And we’re going to talk about that. But for many people, insomnia is an entity all its own. And the DSM-5 says to diagnose someone with insomnia, generally, it is either they have difficulty falling asleep, difficulty staying asleep, or are waking up earlier than is anticipated or desired. These individuals generally have an adequate amount of time to sleep and there are no unusual circumstances (i.e., children waking them up, dogs waking them up, etc.). It needs to be going on at least 3 nights a week for 3 months or longer. And the key is, they need to be dissatisfied with their sleep and that it must be impacting their daytime functioning, whether it be social, whether it be occupational, but it must in some way affect their performance or their activities.

With that said, Debbie, in your population, what do you think is the prevalence of insomnia? Maybe we can talk about insomnia symptoms. What percent of your patients report insomnia symptoms and then what percent do you think actually meet the diagnostic criteria?

Debra Davis, CRNP: In dealing with perimenopausal women, that is one of the biggest complaints that they have that they can’t sleep. And I like what you said about it’s not necessarily a factor of having the dog in the bed. And for my population, it’s not that hot flashes keep them awake, it’s that they honestly can’t sleep.

One of the things that we have studied is sleep-wake time. Say you wake up at 2 in the morning; do you stay awake for 5 minutes or do you stay awake for 2 hours? And, of course, we want that to be as little time as it possibly can be. In my practice, a lot of times people come to me and they’ll say it’s part of perimenopause, or it’s part of man-opause, for a lack of another word. But often you think about people who are depressed and can’t sleep. It can be that somebody’s in a bad situation and they can’t sleep, or they’re stressed and they can’t sleep. But so many times the complaints are: “My mind won’t shut off. I can’t shut my mind off, and that’s why I can’t sleep.”

In sleep, you’ll often think of who can’t go to sleep, who can’t stay asleep, and who doesn’t sleep long enough. For my population, I rarely have someone see me just for insomnia. But even in getting ready for this talk, and just looking at the different disease processes that may or may not be related to insomnia, I’ve thought, do I do an adequate job? Do I do a good enough job thinking: Is this related to sleep? Is this because they can’t sleep? Or is this truly another disease process that they’re going through whereas insomnia is just a sequela of that?

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I think that’s a really good point, because in our clinic we ask about sleep at every follow-up visit. It’s part of our template and we ask about it at every well visit as well. But what I fear is that in today’s environment, where a primary care visit is 16 to 17 minutes long, asking about sleep is like Pandora’s box, right? No one wants to ask about it because if they ask about it, it’s going to mean that they have to do something about it. And historically, many of the drugs that we’ve used have turned out to have long-term adverse consequences, or at least the literature is starting to bear that out.

I agree with you. I think the numbers are somewhere around 70 million people have sleep issues in the United States, but if you drill down, it’s somewhere around 6% to 7% meet those official criteria of insomnia. Do you feel like that’s similar to what you’re seeing?

Debra Davis, CRNP: I do. And one of the things that I was really amazed by was the SHADES [Sleep and Healthy Activity, Diet, Environment and Socialization] study which wasn’t related to any drug. They weren’t looking at drugs. They were looking at just health and wellness. And one of the issues was sleep. They found that 73% of people had problems either going to sleep or staying asleep. But in that same study, they found that 84% of the people had problems with the next day. So many times, when you see somebody, because we all deal with tired, they come in and they’re tired and they don’t know why. “Why am I so tired?” “I don’t know. Let’s delve into why you might be so tired.” But if they have trouble staying awake during the day, if they have trouble with their schoolwork, if they have trouble at work, or needing that extra caffeine, perhaps they didn’t sleep well the night before. That is something that we need to look at more closely.

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I agree with you 100%. We’re going to talk about this as we go through this interaction tonight because we’ve focused so much on what happens at night, but I think what we also need to do is focus on what happens during the day. Because over 80% of people will tell you that they have daytime issues as a result of their sleep. Thank you for bringing that up. I think that’s a really good point.

Transcript edited for clarity